BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDISEASE‐MODIFYING ANTIRHEUMATIC AGENTS ORENCIA INJ 125MG/ML BRAND TIER 03 PA QLORENCIA INJ 250MG BRAND TIER 03 PA QL SPREMICADE INJ 100MG BRAND TIER 03 PA SPSIMPONI INJ 50MG BRAND TIER 03 PA QL SPDISINFECTANTS (FOR NON‐DERMATOLOGIC USE) FORMADON SOL GENERIC TIER 99 DEFORMALDEHYDE SOL 10% GENERIC TIER 99 DEFORMA‐RAY SOL 20% GENERIC TIER 01LAZERFORMALY SOL 10% GENERIC TIER 99 DEGLUTARALDEHY SOL 25% GENERIC TIER 01FORMALDEHYDE SOL 37% GENERIC TIER 01DOPAMINE PRECURSORS CARB/LEVO TAB 10‐100MG GENERIC TIER 01CARB/LEVO TAB 25‐100MG GENERIC TIER 01CARB/LEVO TAB 25‐250MG GENERIC TIER 01CARB/LEVO 50 TAB /ENTACAP GENERIC TIER 01CARB/LEVO 75 TAB /ENTACAP GENERIC TIER 01CARB/LEVO ER TAB 25‐100MG GENERIC TIER 01CARB/LEVO ER TAB 50‐200MG GENERIC TIER 01CARB/LEVO SR TAB 25‐100MG GENERIC TIER 01CARB/LEVO SR TAB 50‐200MG GENERIC TIER 01CARB/LEVO100 TAB /ENTACAP GENERIC TIER 01CARB/LEVO125 TAB /ENTACAP GENERIC TIER 01CARB/LEVO150 TAB /ENTACAP GENERIC TIER 01CARB/LEVO200 TAB /ENTACAP GENERIC TIER 01LODOSYN TAB 25MG BRAND TIER 02PARCOPA TAB 10‐100MG Brand‐O TIER 03 PAPARCOPA TAB 25‐100MG Brand‐O TIER 03 PAPARCOPA TAB 25‐250MG Brand‐O TIER 03 PASINEMET TAB 10‐100MG Brand‐O TIER 03 PASINEMET TAB 25‐100MG Brand‐O TIER 03 PASINEMET TAB 25‐250MG Brand‐O TIER 03 PASINEMET CR TAB 25‐100MG Brand‐O TIER 03 PASINEMET CR TAB 50‐200MG Brand‐O TIER 03 PASTALEVO 100 TAB BRAND TIER 03STALEVO 125 TAB BRAND TIER 03STALEVO 150 TAB BRAND TIER 03STALEVO 200 TAB BRAND TIER 03STALEVO 50 TAB BRAND TIER 03STALEVO 75 TAB BRAND TIER 03Key: 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= DrugExclusion136
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDRUG HYPERSENSITIVITY CANDIN INJ BRAND TIER 03PRE‐PEN INJ BRAND TIER 03ECHINOCANDINS CANCIDAS INJ 50MG BRAND TIER 03CANCIDAS INJ 70MG BRAND TIER 03ERAXIS INJ 100MG BRAND TIER 99 DEERAXIS INJ 50MG BRAND TIER 99 DEMYCAMINE INJ 100MG BRAND TIER 99 DEMYCAMINE INJ 50MG BRAND TIER 03EENT ANTI‐INFECTIVES, MISCELLANEOUS ARZOL SILVER MIS NITR APP GENERIC TIER 01BETADINE SOL 5% OP BRAND TIER 03CHLORHEX GLU SOL 0.12% GENERIC TIER 01GRAFCO SILVR MIS NIT APPL GENERIC TIER 01PERIDEX SOL 0.12% Brand‐O TIER 03 PAPERIOGARD SOL 0.12% GENERIC TIER 01SILVER CRY NITRATE GENERIC TIER 99 DESILVER NITRA OIN 10% GENERIC TIER 01SILVER NITRA SOL 0.5% GENERIC TIER 01SILVER NITRA SOL 10% GENERIC TIER 01SILVER NITRA SOL 25% GENERIC TIER 01SILVER NITRA SOL 50% GENERIC TIER 01EENT ANTI‐INFLAMMATORY AGENTS, MISC. RESTASIS EMU 0.05% BRAND TIER 02 PA QLEENT DRUGS, MISCELLANEOUS ACE ACD/ALUM SOL 2% OTIC GENERIC TIER 01ACETIC ACID SOL 2% OTIC GENERIC TIER 01AKORN BALANC SOL SALT OP GENERIC TIER 01AMVISC INJ 12MG/ML BRAND TIER 03AMVISC PLUS INJ 16MG/ML BRAND TIER 03APHTHASOL PST 5% BRAND TIER 03APRACLONIDIN SOL 0.5% OP GENERIC TIER 01AQUORAL AER GENERIC TIER 01BAL SALT SOL OP GENERIC TIER 01BALANCED SAL SOL OP GENERIC TIER 01BSS SOL OP GENERIC TIER 01BSS PLUS SOL OP Brand‐O TIER 03 PACAPHOSOL SOL BRAND TIER 03CELLUGEL SOL 2% Brand‐O TIER 03 PADEBACTEROL SOL 30‐50% BRAND TIER 03DISCOVISC SOL BRAND TIER 03DUOVISC KIT 0.35/0.4 BRAND TIER 03DUOVISC KIT 0.5/0.55 BRAND TIER 03Key: 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= DrugExclusion137
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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