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 StatusERYTHROMYCINS ERYTHROCIN TAB 250MG BRAND TIER 03ERYTHROCIN TAB 250MG GENERIC TIER 01ERYTHROM ETH TAB 400MG GENERIC TIER 01ERYTHROMYCIN CAP 250MG EC GENERIC TIER 01ERYTHROMYCIN TAB 250MG BS GENERIC TIER 01ERYTHROMYCIN TAB 500MG BS GENERIC TIER 01PCE TAB 333MG EC BRAND TIER 03PCE TAB 500MG EC BRAND TIER 03ESTROGEN AGONIST‐ANTAGONISTS CLOMIPHENE TAB 50MG GENERIC TIER 99 DEEVISTA TAB 60MG BRAND TIER 02SEROPHENE TAB 50MG GENERIC TIER 99 DECLOMID TAB 50MG Brand‐O TIER 99 PA DEESTROGENS ACTIVELLA TAB 0.5‐0.1 Brand‐O TIER 03 PAACTIVELLA TAB 1‐0.5MG Brand‐O TIER 03 PAALORA DIS 0.025MG BRAND TIER 03ALORA DIS 0.05MG BRAND TIER 03ALORA DIS 0.075MG BRAND TIER 03ALORA DIS 0.1MG BRAND TIER 03ANGELIQ TAB 0.25‐0.5 BRAND TIER 03ANGELIQ TAB 0.5‐1MG BRAND TIER 03CENESTIN TAB 0.3MG BRAND TIER 02CENESTIN TAB 0.45MG BRAND TIER 02CENESTIN TAB 0.625MG BRAND TIER 02CENESTIN TAB 0.9MG BRAND TIER 02CENESTIN TAB 1.25MG BRAND TIER 02CLIMARA DIS 0.025MG Brand‐O TIER 02 PACLIMARA DIS 0.0375MG Brand‐O TIER 02 PACLIMARA DIS 0.05MG Brand‐O TIER 02 PACLIMARA DIS 0.06MG Brand‐O TIER 02 PACLIMARA DIS 0.075MG Brand‐O TIER 02 PACLIMARA DIS 0.1MG Brand‐O TIER 02 PACLIMARA PRO DIS WEEKLY BRAND TIER 03COMBIPATCH DIS .05/.14 BRAND TIER 02COMBIPATCH DIS .05/.25 BRAND TIER 02COVARYX TAB GENERIC TIER 99 DECOVARYX HS TAB GENERIC TIER 99 DEDELESTROGEN INJ 10MG/ML Brand‐O TIER 03 PADELESTROGEN INJ 20MG/ML Brand‐O TIER 03 PADELESTROGEN INJ 40MG/ML 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= DrugExclusion140