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 StatusANALGESICS AND ANTIPYRETICS, MISC. CAFGESIC TAB GENERIC TIER 01CAPACET CAP GENERIC TIER 01CEPHADYN TAB 50‐650MG GENERIC TIER 01DOLGIC PLUS TAB BRAND TIER 03DURABAC CAP Brand‐O TIER 03 PADURABAC TAB FORTE BRAND TIER 03DURAXIN CAP GENERIC TIER 01ED‐FLEX CAP GENERIC TIER 01ESGIC CAP Brand‐O TIER 03 PAESGIC TAB Brand‐O TIER 03 PAESGIC‐PLUS CAP Brand‐O TIER 03 PAESGIC‐PLUS TAB Brand‐O TIER 03 PAFIORICET TAB Brand‐O TIER 03 PAFRENADOL TAB GENERIC TIER 01GRALISE TAB 300MG BRAND TIER 03 PA QLGRALISE TAB 600MG BRAND TIER 03 PA QLGRALISE STAR MIS 300/600 BRAND TIER 03ILARIS INJ 180MG BRAND TIER 03 PA QL SPMARGESIC CAP GENERIC TIER 01MARTEN‐TAB TAB 50‐325MG GENERIC TIER 01OFIRMEV INJ 10MG/ML BRAND TIER 03ORBIVAN CAP BRAND TIER 03ORBIVAN CF TAB 50‐300MG BRAND TIER 03PHRENILIN CAP FORTE BRAND TIER 03PRIALT INJ 100MCG BRAND TIER 99 DEPRIALT INJ 25MCG/ML BRAND TIER 99 DEPRIALT INJ 500MCG BRAND TIER 99 DEPROMACET TAB 50‐650MG GENERIC TIER 01REPAN TAB GENERIC TIER 01SEDAPAP TAB 50‐650MG Brand‐O TIER 03 PATENCON TAB 50‐650MG GENERIC TIER 01ZEBUTAL CAP GENERIC TIER 01ANDROGENS ANADROL‐50 TAB 50MG BRAND TIER 03 PAANDRODERM DIS 2.5MG/24 BRAND TIER 02ANDRODERM DIS 2MG/24HR BRAND TIER 02ANDRODERM DIS 4MG/24HR BRAND TIER 02ANDRODERM DIS 5MG/24HR BRAND TIER 02ANDROGEL GEL 1%(25MG) BRAND TIER 02ANDROGEL GEL 1%(50MG) BRAND TIER 02Key: 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= DrugExclusion12