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 StatusDIAGNOSTIC AGENTS CHOLETEC INJ BRAND TIER 99 DECYSVIEW INJ 100MG BRAND TIER 99 DEDATSCAN SOL BRAND TIER 99 DEDEFINITY SUS 1.1MG/ML BRAND TIER 99 DEDIAGNOSTIC KIT GENERIC TIER 99 DEEOVIST INJ BRAND TIER 99 DEINDIUM IN111 INJ OXYQUINO GENERIC TIER 99 DEISOSULFAN INJ BLUE 1% GENERIC TIER 99 DELYMPHAZURIN INJ 1% Brand‐O TIER 99 DEMAGNEVIST INJ 46.9% BRAND TIER 99 DEMDP KIT MULTIDOS BRAND TIER 99 DEMETHACHOLINE CRY CHLORIDE GENERIC TIER 99 DEOMNISCAN INJ /NACL BRAND TIER 99 DEOMNISCAN INJ 287MG/ML BRAND TIER 99 DEOPTIMARK INJ 330.9MG BRAND TIER 99 DEOPTISON INJ BRAND TIER 99 DEPROHANCE INJ 279.3/ML BRAND TIER 99 DEPROVOCHOLINE SOL 100MG BRAND TIER 99 DET.R.U.E. TES BRAND TIER 99 DETHYREL TRH INJ 0.5MG/ML BRAND TIER 99 DEDIGESTANTS CREON CAP 12000UNT BRAND TIER 02CREON CAP 24000UNT BRAND TIER 02CREON CAP 3000UNIT BRAND TIER 02CREON CAP 6000UNIT BRAND TIER 02HYDROCHLORIC INJ 1:500 GENERIC TIER 01PANCREAZE CAP 10500UNT BRAND TIER 03PANCREAZE CAP 16800UNT BRAND TIER 03PANCREAZE CAP 21000UNT BRAND TIER 03PANCREAZE CAP 4200UNIT BRAND TIER 03PANCRELIPASE CAP 5000UNIT GENERIC TIER 01PERTZYE CAP BRAND TIER 03VIOKACE TAB BRAND TIER 03ZENPEP CAP 10000UNT BRAND TIER 02ZENPEP CAP 15000UNT BRAND TIER 02ZENPEP CAP 20000UNT BRAND TIER 02ZENPEP CAP 25000UNT BRAND TIER 02ZENPEP CAP 3000UNIT BRAND TIER 02ZENPEP CAP 5000UNIT BRAND TIER 02DIHYDROPYRIDINES ADALAT CC TAB 30MG ER 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= DrugExclusion130