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 StatusESTROGENS VAGIFEM TAB 10MCG BRAND TIER 02VIVELLE‐DOT DIS 0.025MG BRAND TIER 02VIVELLE‐DOT DIS 0.0375MG BRAND TIER 02VIVELLE‐DOT DIS 0.05MG BRAND TIER 02VIVELLE‐DOT DIS 0.075MG BRAND TIER 02VIVELLE‐DOT DIS 0.1MG BRAND TIER 02ETHANOLAMINE DERIVATIVES ACUFLEX TAB BRAND TIER 03ALI‐FLEX TAB 50‐500MG GENERIC TIER 01ALPAIN TAB GENERIC TIER 01ARBINOXA LIQ 4MG/5ML GENERIC TIER 01ARBINOXA TAB 4MG GENERIC TIER 01BIOGESIC TAB 30‐500MG GENERIC TIER 01BIOREGESIC TAB 50‐650MG BRAND TIER 03BP POLY‐650 TAB GENERIC TIER 01CARBINOXAMIN LIQ 4MG/5ML GENERIC TIER 01CARBINOXAMIN TAB 4MG GENERIC TIER 01CLEMASTINE SYP 0.5/5ML GENERIC TIER 01CLEMASTINE TAB 2.68MG GENERIC TIER 01DIPHENHYDRAM ELX 12.5/5ML GENERIC TIER 01DIPHENHYDRAM INJ 50MG/ML GENERIC TIER 01DOLOGESIC LIQ 30‐500MG BRAND TIER 03DOLOGESIC TAB 30‐500MG GENERIC TIER 01DOLOREX TAB 50‐500MG GENERIC TIER 01DOXYTEX LIQ BRAND TIER 03DYTUSS SYP 12.5/5ML GENERIC TIER 01FLEXTRA CAP BRAND TIER 03FLEXTRA DS TAB 50‐500MG Brand‐O TIER 03 PAFLEXTRA‐650 TAB Brand‐O TIER 03 PALAGESIC TAB 66‐600MG Brand‐O TIER 03 PANOVAGESIC TAB 30‐500MG GENERIC TIER 01PALGIC LIQ 4MG/5ML Brand‐O TIER 03 PAPALGIC TAB 4MG Brand‐O TIER 03 PARELAGESIC LIQ 5‐160MG BRAND TIER 03RELAGESIC TAB 50‐650MG BRAND TIER 03RHINOFLEX TAB 50‐500MG GENERIC TIER 01RHINOFLEX TAB 50‐650MG GENERIC TIER 01STAFLEX TAB 55‐500MG Brand‐O TIER 03 PATEKRAL TAB BRAND TIER 99 DEZFLEX TAB 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= DrugExclusion143