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 StatusAMPHETAMINES AMPHETAMINE TAB 10MG GENERIC TIER 01 QLAMPHETAMINE TAB 12.5MG GENERIC TIER 01 QLAMPHETAMINE TAB 15MG GENERIC TIER 01 QLAMPHETAMINE TAB 20MG GENERIC TIER 01 QLAMPHETAMINE TAB 30MG GENERIC TIER 01 QLAMPHETAMINE TAB 5MG GENERIC TIER 01 QLAMPHETAMINE TAB 7.5MG GENERIC TIER 01 QLBENZPHETAMIN TAB 50MG GENERIC TIER 99 DEDESOXYN TAB 5MG Brand‐O TIER 03 PADEXEDRINE CAP 10MG CR Brand‐O TIER 03 PA QLDEXEDRINE CAP 15MG CR Brand‐O TIER 03 PA QLDEXEDRINE CAP 5MG CR Brand‐O TIER 03 PA QLDEXTROAMPHET CAP 10MG ER GENERIC TIER 01 QLDEXTROAMPHET CAP 15MG ER GENERIC TIER 01 QLDEXTROAMPHET CAP 5MG ER GENERIC TIER 01 QLDEXTROAMPHET TAB 10MG GENERIC TIER 01 QLDEXTROAMPHET TAB 5MG GENERIC TIER 01 QLMETHAMPHETAM TAB 5MG GENERIC TIER 01PROCENTRA SOL 5MG/5ML BRAND TIER 03REGIMEX TAB 25MG BRAND TIER 99 DEVYVANSE CAP 20MG BRAND TIER 02 PA QLVYVANSE CAP 30MG BRAND TIER 02 PA QLVYVANSE CAP 40MG BRAND TIER 02 PA QLVYVANSE CAP 50MG BRAND TIER 02 PA QLVYVANSE CAP 60MG BRAND TIER 02 PA QLVYVANSE CAP 70MG BRAND TIER 02 PA QLDIDREX TAB 50MG Brand‐O TIER 99 PA DEAMYLINOMIMETICS SYMLIN INJ 600MCG BRAND TIER 02SYMLINPEN 60 INJ 1000MCG BRAND TIER 02SYMLNPEN 120 INJ 1000MCG BRAND TIER 02ANALGESICS AND ANTIPYRETICS, MISC. ALAGESIC CAP GENERIC TIER 01ALAGESIC LQ SOL BRAND TIER 03ANABAR TAB GENERIC TIER 01ANOLOR 300 CAP GENERIC TIER 01BUPAP TAB 50‐650MG GENERIC TIER 01BUT/APAP/CAF CAP GENERIC TIER 01BUT/APAP/CAF TAB GENERIC TIER 01BUTAL/APAP TAB 50‐325MG GENERIC TIER 01CAFGESIC CAP 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= DrugExclusion11