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 StatusETHANOLAMINE DERIVATIVES ZGESIC TAB 66‐600MG GENERIC TIER 01DIPHENHYDRAM CAP 50MG GENERIC TIER 01ETHYLENEDIAMINE DERIVATIVES PYRILAMINE CRY USP NF GENERIC TIER 99 DERYNA‐12 TAB 60‐25MG BRAND TIER 99 DEEXPECTORANTS DECON‐G DRO 2‐1‐40MG BRAND TIER 99 DEEXEFEN‐IR TAB 60‐400MG GENERIC TIER 99 DEG/P TAB 1200‐75 GENERIC TIER 99 DEGANIDIN‐NR LIQ 100/5ML GENERIC TIER 99 DEGENEXA LA CAP 30‐400MG GENERIC TIER 99 DEGFN550/PSE60 TAB GENERIC TIER 99 DEGG/PE SYP GENERIC TIER 99 DEGILPHEX TR TAB 10‐388MG BRAND TIER 99 DEIODINE SOL STRONG GENERIC TIER 01KGS‐PE LIQ 5MG‐75MG GENERIC TIER 99 DELEMOHIST CAP PLUS BRAND TIER 99 DEORGANIDIN NR TAB 200MG GENERIC TIER 99 DEPE/GUAIFENES DRO 1.5‐20MG GENERIC TIER 99 DEPE‐GUAI DRO 1.5‐20MG GENERIC TIER 99 DEQUAL‐TUSSIN DRO PED GENERIC TIER 99 DERYNA‐12X TAB BRAND TIER 99 DESIMUC‐GP TAB 25‐1200 GENERIC TIER 99 DESINA‐12X TAB 25‐200MG BRAND TIER 99 DETUSNEL CAP BRAND TIER 99 DETUSSI PRES‐B LIQ GENERIC TIER 99 DEZOTEX‐GP TAB BRAND TIER 99 DENARIZ LIQ 7.5‐200 Brand‐O TIER 99 PA DEEXTENDED‐SPECTRUM PENICILLINS PIPER/TAZOBA INJ 2‐0.25GM GENERIC TIER 01PIPER/TAZOBA INJ 3‐0.375G GENERIC TIER 01PIPER/TAZOBA INJ 36‐4.5GM GENERIC TIER 01PIPER/TAZOBA INJ 4‐0.5GM GENERIC TIER 01TIMENTIN INJ 3.1GM BRAND TIER 03TIMENTIN INJ 31GM BRAND TIER 03ZOSYN INJ 2‐0.25GM Brand‐O TIER 03 PAZOSYN INJ 3‐0.375G Brand‐O TIER 03 PAZOSYN INJ 36‐4.5GM Brand‐O TIER 03 PAZOSYN INJ 4‐0.5GM Brand‐O TIER 03 PAZOSYN SOL 2‐0.25GM BRAND TIER 03ZOSYN SOL 3‐0.375G BRAND TIER 03ZOSYN SOL 4‐0.50GM 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= DrugExclusion144
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusFIBRIC ACID DERIVATIVES ANTARA CAP 130MG BRAND TIER 02 PA QLANTARA CAP 43MG BRAND TIER 02 PA QLFENOFIBRATE CAP 134MG GENERIC TIER 01 PA QLFENOFIBRATE CAP 200MG GENERIC TIER 01 PA QLFENOFIBRATE CAP 67MG GENERIC TIER 01 PA QLFENOFIBRATE TAB 160MG GENERIC TIER 01 PA QLFENOFIBRATE TAB 54MG GENERIC TIER 01 PA QLFENOFIBRIC TAB 105MG GENERIC TIER 01 PA QLFENOFIBRIC TAB 35MG GENERIC TIER 01 PA QLFENOGLIDE TAB 120MG BRAND TIER 02 PA QLFENOGLIDE TAB 40MG BRAND TIER 02 PA QLFIBRICOR TAB 105MG BRAND TIER 03 PA QLFIBRICOR TAB 35MG BRAND TIER 03 PA QLGEMFIBROZIL TAB 600MG GENERIC TIER 01LIPOFEN CAP 150MG BRAND TIER 02 PA QLLIPOFEN CAP 50MG BRAND TIER 02 PA QLLOFIBRA CAP 134MG Brand‐O TIER 03 PA QLLOFIBRA CAP 200MG Brand‐O TIER 03 PA QLLOFIBRA CAP 67MG Brand‐O TIER 03 PA QLLOFIBRA TAB 160MG Brand‐O TIER 03 PA QLLOFIBRA TAB 54MG Brand‐O TIER 03 PA QLLOPID TAB 600MG Brand‐O TIER 03 PATRICOR TAB 145MG BRAND TIER 02 PA QLTRICOR TAB 48MG BRAND TIER 02 PA QLTRIGLIDE TAB 160MG BRAND TIER 02 PA QLTRIGLIDE TAB 50MG BRAND TIER 02 PA QLTRILIPIX CAP 135MG BRAND TIER 02 PA QLTRILIPIX CAP 45MG BRAND TIER 02 PA QLFIBROMYALGIA AGENTS SAVELLA MIS TITR PAK BRAND TIER 03 QLSAVELLA TAB 100MG BRAND TIER 02 PA QLSAVELLA TAB 12.5MG BRAND TIER 02 PA QLSAVELLA TAB 25MG BRAND TIER 02 PA QLSAVELLA TAB 50MG BRAND TIER 02 PA QLFIFTH GENERATION CEPHALOSPORINS TEFLARO INJ 400MG BRAND TIER 03TEFLARO INJ 600MG BRAND TIER 03FIRST GEN. ANTIHIST. DERIVATIVES, MISC. CYPROHEPTAD SYP 2MG/5ML GENERIC TIER 01CYPROHEPTAD TAB 4MG GENERIC TIER 01NOREL SR TAB BRAND TIER 99 DEFIRST GENERATION CEPHALOSPORINS CEFADROXIL CAP 500MG 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= DrugExclusion145
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BMC HealthNet Plan Drug List - Comm
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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