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 StatusFIRST GENERATION CEPHALOSPORINS CEFADROXIL SUS 250/5ML GENERIC TIER 01CEFADROXIL SUS 500/5ML GENERIC TIER 01CEFADROXIL TAB 1GM GENERIC TIER 01CEFAZOL/DEX SOL 1GM GENERIC TIER 99 DECEFAZOL/DEX SOL 2GM GENERIC TIER 99 DECEFAZOLIN INJ 100GM GENERIC TIER 01CEFAZOLIN INJ 10GM GENERIC TIER 01CEFAZOLIN INJ 1GM GENERIC TIER 01CEFAZOLIN INJ 1GM/50ML GENERIC TIER 01CEFAZOLIN INJ 20GM GENERIC TIER 01CEFAZOLIN INJ 300GM GENERIC TIER 01CEFAZOLIN INJ 500MG GENERIC TIER 01CEPHALEXIN CAP 250MG GENERIC TIER 01CEPHALEXIN CAP 500MG GENERIC TIER 01CEPHALEXIN SUS 125/5ML GENERIC TIER 01CEPHALEXIN SUS 250/5ML GENERIC TIER 01CEPHALEXIN TAB 250MG GENERIC TIER 01CEPHALEXIN TAB 500MG GENERIC TIER 01KEFLEX CAP 250MG Brand‐O TIER 03 PAKEFLEX CAP 500MG Brand‐O TIER 03 PAKEFLEX CAP 750MG BRAND TIER 03FOURTH GENERATION CEPHALOSPORINS CEFEPIME INJ 1GM GENERIC TIER 01CEFEPIME INJ 2GM GENERIC TIER 01GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT BACLOFEN TAB 10MG GENERIC TIER 01BACLOFEN TAB 20MG GENERIC TIER 01ED BACLOFEN TAB 10MG GENERIC TIER 01GABLOFEN INJ 10000/20 BRAND TIER 03 SPGABLOFEN INJ 20000/20 BRAND TIER 03 SPGABLOFEN INJ 40000/20 BRAND TIER 03 SPGABLOFEN INJ 50MCG/ML BRAND TIER 03 SPLIORESAL INT INJ 0.05MG/1 BRAND TIER 03 SPLIORESAL INT INJ 10MG/20 BRAND TIER 03 SPLIORESAL INT INJ 10MG/5ML BRAND TIER 03 SPLIORESAL INT INJ 40MG/20 BRAND TIER 03 SPGALLBLADDER FUNCTION KINEVAC INJ 5MCG BRAND TIER 03GENERAL ANESTHETICS, MISCELLANEOUS AMIDATE INJ 2MG/ML Brand‐O TIER 03 PADIPRIVAN INJ 10MG/ML Brand‐O TIER 03 PAETOMIDATE INJ 2MG/ML 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= DrugExclusion146