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 StatusAMINOPENICILLINS AUGMENTIN XR TAB 12HR Brand‐O TIER 03 PAMOXATAG TAB 775MG BRAND TIER 03UNASYN INJ 1.5GM Brand‐O TIER 03 PAUNASYN INJ 1.5GM PB Brand‐O TIER 03 PAUNASYN INJ 15GM Brand‐O TIER 03 PAUNASYN INJ 3GM Brand‐O TIER 03 PAUNASYN INJ 3GM PB Brand‐O TIER 03 PAAUGMENTIN SUS ES‐600 Brand‐O TIER 03 PAAMMONIA DETOXICANTS AMMONUL INJ 10% BRAND TIER 03BUPHENYL POW BRAND TIER 02BUPHENYL TAB 500MG BRAND TIER 02CARBAGLU TAB 200MG BRAND TIER 02CONSTULOSE SOL 10GM/15 GENERIC TIER 01ENULOSE SOL 10GM/15 GENERIC TIER 01GENERLAC SOL 10GM/15 GENERIC TIER 01KRISTALOSE PAK 10GM BRAND TIER 02KRISTALOSE PAK 20GM BRAND TIER 02LACTULOSE SOL 10GM/15 GENERIC TIER 01LACTULOSE SOL 20GM/30 GENERIC TIER 01LITHOSTAT TAB 250MG BRAND TIER 03AMPHETAMINES ADDERALL TAB 10MG Brand‐O TIER 03 PA QLADDERALL TAB 12.5MG Brand‐O TIER 03 PA QLADDERALL TAB 15MG Brand‐O TIER 03 PA QLADDERALL TAB 20MG Brand‐O TIER 03 PA QLADDERALL TAB 30MG Brand‐O TIER 03 PA QLADDERALL TAB 5MG Brand‐O TIER 03 PA QLADDERALL TAB 7.5MG Brand‐O TIER 03 PA QLADDERALL XR CAP 10MG Brand‐O TIER 03 PA QLADDERALL XR CAP 15MG Brand‐O TIER 03 PA QLADDERALL XR CAP 20MG Brand‐O TIER 03 PA QLADDERALL XR CAP 25MG Brand‐O TIER 03 PA QLADDERALL XR CAP 30MG Brand‐O TIER 03 PA QLADDERALL XR CAP 5MG Brand‐O TIER 03 PA QLAMPHETAMINE CAP 10MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 15MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 20MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 25MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 30MG ER GENERIC TIER 01 PA QLAMPHETAMINE CAP 5MG ER GENERIC TIER 01 PA QLKey: 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= DrugExclusion10