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) NEO/POLY/HC SUS OP GENERIC TIER 01OMNARIS SPR BRAND TIER 03 PAOMNIPRED SUS 1% OP Brand‐O TIER 03 PAOTO‐END 10 SOL GENERIC TIER 99 DEOTOMAR SOL OTIC GENERIC TIER 99 DEOTOMAX‐HC DRO GENERIC TIER 99 DEOZURDEX IMP 0.7MG BRAND TIER 02POLY‐DEX OIN 0.1% OP GENERIC TIER 01POLY‐PRED SUS OP BRAND TIER 03PRAMOXINE‐HC DRO AQ OTIC GENERIC TIER 99 DEPRED FORTE SUS 1% OP Brand‐O TIER 03 PAPRED MILD SUS 0.12% OP BRAND TIER 02PRED SOD PHO SOL 1% OP GENERIC TIER 01PRED‐G SUS OP BRAND TIER 03PRED‐G S.O.P OIN OP BRAND TIER 03PREDNISOLONE SUS 1% OP GENERIC TIER 01QNASL AER 80MCG BRAND TIER 03RETISERT IMP 0.59MG BRAND TIER 02RHINOCORT SUS AQUA BRAND TIER 02 PASULF/PRED NA SOL OP GENERIC TIER 01TOBRA/DEXAME SUS 0.3‐0.1% GENERIC TIER 01 PATOBRADEX OIN 0.3‐0.1% BRAND TIER 02TOBRADEX SUS 0.3‐0.1% Brand‐O TIER 03 PATOBRADEX ST SUS 0.3‐0.05 BRAND TIER 02 PATRIAMCINOLON SPR 55MCG/AC GENERIC TIER 01 PATRIESENCE INJ 40MG/ML BRAND TIER 99 DEVERAMYST SPR 27.5MCG BRAND TIER 02 PAVEXOL SUS 1% OP BRAND TIER 03VOSOL HC SOL OTIC Brand‐O TIER 03 PAZETONNA AER 37MCG BRAND TIER 03 PAZYLET SUS 0.5‐0.3% BRAND TIER 02 PACORTANE‐B DRO OTIC Brand‐O TIER 99 PA DECORTANE‐B DRO AQ OTIC Brand‐O TIER 99 PA DEOTICIN HC DRO Brand‐O TIER 99 PA DECOUMARIN DERIVATIVES COUMADIN INJ 5 MG BRAND TIER 03COUMADIN TAB 10MG Brand‐O TIER 03 PACOUMADIN TAB 1MG Brand‐O TIER 03 PACOUMADIN TAB 2.5MG Brand‐O TIER 03 PACOUMADIN TAB 2MG Brand‐O TIER 03 PAKey: 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= DrugExclusion99