BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCORTICOSTEROIDS (EENT) BECONASE AQ SUS 0.042% BRAND TIER 03 PABLEPHAMIDE OIN S.O.P. BRAND TIER 02BLEPHAMIDE SUS OP BRAND TIER 03CIPRO HC SUS OTIC BRAND TIER 03CIPRODEX SUS 0.3‐0.1% BRAND TIER 02COLY‐MYCIN S SUS OTIC BRAND TIER 03CORTIC‐ND DRO GENERIC TIER 99 DECORTISPORIN SOL 1% OTIC Brand‐O TIER 03 PACORTISPORIN SUS ‐TC OTIC BRAND TIER 03CORTOMYCIN SUS 1% OTIC GENERIC TIER 01CYOTIC DRO GENERIC TIER 99 DEDERMOTIC OIL 0.01% Brand‐O TIER 03 PADEXAMETH PHO SOL 0.1% OP GENERIC TIER 01DUREZOL EMU 0.05% BRAND TIER 02 PAEXOTIC‐HC DRO OTIC GENERIC TIER 99 DEFLAREX SUS 0.1% OP BRAND TIER 03FLONASE SPR 0.05% Brand‐O TIER 03 PAFLUNISOLIDE SPR 0.025% GENERIC TIER 01FLUNISOLIDE SPR 29MCG GENERIC TIER 01FLUOCIN ACET OIL 0.01% GENERIC TIER 01FLUOROMETHOL SUS 0.1% OP GENERIC TIER 01FLUOR‐OP SUS 0.1% OP GENERIC TIER 01FLUTICASONE SPR 50MCG GENERIC TIER 01FML OIN 0.1% OP BRAND TIER 02FML FORTE SUS 0.25% OP BRAND TIER 03FML LIQUIFLM SUS 0.1% OP Brand‐O TIER 03 PAHC/ACET ACID SOL OTIC GENERIC TIER 01LOTEMAX OIN 0.5% BRAND TIER 03 PALOTEMAX SUS 0.5% BRAND TIER 02 PAMAXIDEX SUS 0.1% OP BRAND TIER 03MAXITROL OIN 0.1% OP Brand‐O TIER 03 PAMAXITROL SUS 0.1% OP Brand‐O TIER 03 PANASACORT AQ AER 55MCG/AC Brand‐O TIER 03 PANASONEX SPR 50MCG/AC BRAND TIER 02 PANEO/POLY/BAC OIN /HC 1%OP GENERIC TIER 01NEO/POLY/DEX OIN 0.1% OP GENERIC TIER 01NEO/POLY/DEX SUS 0.1% OP GENERIC TIER 01NEO/POLY/HC SOL 1% OTIC GENERIC TIER 01NEO/POLY/HC SUS 1% OTIC GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion98