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 StatusCOUMARIN DERIVATIVES COUMADIN TAB 3MG Brand‐O TIER 03 PACOUMADIN TAB 4MG Brand‐O TIER 03 PACOUMADIN TAB 5MG Brand‐O TIER 03 PACOUMADIN TAB 6MG Brand‐O TIER 03 PACOUMADIN TAB 7.5MG Brand‐O TIER 03 PAJANTOVEN TAB 10MG GENERIC TIER 01JANTOVEN TAB 1MG GENERIC TIER 01JANTOVEN TAB 2.5MG GENERIC TIER 01JANTOVEN TAB 2MG GENERIC TIER 01JANTOVEN TAB 3MG GENERIC TIER 01JANTOVEN TAB 4MG GENERIC TIER 01JANTOVEN TAB 5MG GENERIC TIER 01JANTOVEN TAB 6MG GENERIC TIER 01JANTOVEN TAB 7.5MG GENERIC TIER 01WARFARIN TAB 10MG GENERIC TIER 01WARFARIN TAB 1MG GENERIC TIER 01WARFARIN TAB 2.5MG GENERIC TIER 01WARFARIN TAB 2MG GENERIC TIER 01WARFARIN TAB 3MG GENERIC TIER 01WARFARIN TAB 4MG GENERIC TIER 01WARFARIN TAB 5MG GENERIC TIER 01WARFARIN TAB 6MG GENERIC TIER 01WARFARIN TAB 7.5MG GENERIC TIER 01CYCLIC LIPOPEPTIDES CUBICIN SOL 500MG BRAND TIER 03CYCLOOXYGENASE‐2 (COX‐2) INHIBITORS CELEBREX CAP 100MG BRAND TIER 02 PA QLCELEBREX CAP 200MG BRAND TIER 02 PA QLCELEBREX CAP 400MG BRAND TIER 02 PA QLCELEBREX CAP 50MG BRAND TIER 02 PA QLDENTAL AGENTS FLUORIDEX GEL SENSITIV BRAND TIER 03FLUORIDEX DD PST SENSITIV GENERIC TIER 01MI PASTE PST BRAND TIER 03MI PLUS PST BRAND TIER 03NAFRINSE SOL DAILY BRAND TIER 03PREVIDENT PST 5000 SEN Brand‐O TIER 03 PAPRVDNT 5000 PST ENAML PR Brand‐O TIER 03 PAQ4 ORAL CLEA KIT SYSTEM BRAND TIER 03REMESENSE MIS BRAND TIER 03Q2 ORAL CLEA KIT SYSTEM BRAND TIER 03DEPIGMENTING AGENTS ACLARO EMU BRAND TIER 99 DEKey: 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= DrugExclusion100