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 StatusGENERAL ANESTHETICS, MISCELLANEOUS KETAMINE INJ 100MG/ML GENERIC TIER 99 DEKETAMINE INJ 10MG/ML GENERIC TIER 99 DEKETAMINE INJ 50MG/ML GENERIC TIER 99 DELUSEDRA INJ BRAND TIER 03PROPOFOL INJ 10MG/ML GENERIC TIER 01PROPOVEN INJ 10MG/ML GENERIC TIER 01KETALAR INJ 10MG/ML Brand‐O TIER 99 PA DEKETALAR INJ 50MG/ML Brand‐O TIER 99 PA DEKETALAR INJ 100MG/ML Brand‐O TIER 99 PA DEGENITOURINARY SMOOTH MUSCLE RELAXANTS DETROL TAB 1MG Brand‐O TIER 03 PADETROL TAB 2MG Brand‐O TIER 03 PADETROL LA CAP 2MG BRAND TIER 02 QLDETROL LA CAP 4MG BRAND TIER 02 QLDITROPAN XL TAB 10MG Brand‐O TIER 03 PADITROPAN XL TAB 15MG Brand‐O TIER 03 PADITROPAN XL TAB 5MG Brand‐O TIER 03 PAENABLEX TAB 15MG BRAND TIER 02 QLENABLEX TAB 7.5MG BRAND TIER 02 QLFLAVOXATE TAB 100MG GENERIC TIER 01GELNIQUE GEL 10% BRAND TIER 02 PA QLGELNIQUE GEL 3% BRAND TIER 02 PA QLMYRBETRIQ TAB 25MG BRAND TIER 03MYRBETRIQ TAB 50MG BRAND TIER 03OXYBUTYNIN SYP 5MG/5ML GENERIC TIER 01OXYBUTYNIN TAB 10MG ER GENERIC TIER 01OXYBUTYNIN TAB 15MG ER GENERIC TIER 01OXYBUTYNIN TAB 5MG GENERIC TIER 01OXYBUTYNIN TAB 5MG ER GENERIC TIER 01OXYTROL DIS 3.9MG/24 BRAND TIER 02 PA QLSANCTURA TAB 20MG Brand‐O TIER 03 PASANCTURA XR CAP 60MG Brand‐O TIER 02 PATOLTERODINE TAB 1MG GENERIC TIER 01TOLTERODINE TAB 2MG GENERIC TIER 01TOVIAZ TAB 4MG BRAND TIER 02TOVIAZ TAB 8MG BRAND TIER 02TROSPIUM CL TAB 20MG GENERIC TIER 01VESICARE TAB 10MG BRAND TIER 02 QLVESICARE TAB 5MG BRAND TIER 02 QLKey: 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= DrugExclusion147