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 StatusIRON PREPARATIONS NEPHRON FA TAB BRAND TIER 03NIRON KOMPLE TAB 30‐1MG BRAND TIER 03NOVAFERRUM SOL BRAND TIER 03NULECIT INJ 12.5MG/M GENERIC TIER 01POLY‐IRON CAP 150 FORT GENERIC TIER 01POLYSACCHARI CAP IRON GENERIC TIER 01PROFERRIN‐ TAB FORTE BRAND TIER 03PROMAR CAP BRAND TIER 03PUREFE CAP PLUS BRAND TIER 03PUREVIT DUAL CAP FE PLUS GENERIC TIER 01RENATABS MIS IRON BRAND TIER 03SENILEZOL ELX GENERIC TIER 01SE‐TAN PLUS CAP GENERIC TIER 01TANDEM F CAP GENERIC TIER 01TANDEM PLUS CAP Brand‐O TIER 03 PATARON FORTE CAP BRAND TIER 03TL ICON CAP GENERIC TIER 01TL‐FOL 500 TAB GENERIC TIER 01TL‐HEM 150 TAB GENERIC TIER 01TRICON CAP GENERIC TIER 01TRIGELS‐F CAP FORTE GENERIC TIER 01VENOFER INJ 20MG/ML BRAND TIER 03VITAFOL SYP BRAND TIER 03VITAFOL TAB Brand‐O TIER 03 PAFERROUS SULF GRA GENERIC TIER 99 DEIRRIGATING SOLUTIONS ACETIC ACID SOL 0.25%IRR GENERIC TIER 01AMINOAC ACID SOL 1.5% IRR GENERIC TIER 01CURITY SALIN SOL 0.9% IRR GENERIC TIER 01DELFLEX‐LC/ SOL 1.5% DEX GENERIC TIER 01DELFLEX‐LC/ SOL 2.5% DEX GENERIC TIER 01DELFLEX‐LC/ SOL 4.25 DEX GENERIC TIER 01DELFLEX‐LM SOL 1.5% DEX GENERIC TIER 01DELFLEX‐LM SOL 2.5% DEX GENERIC TIER 01DELFLEX‐LM/ SOL 4.25 DEX GENERIC TIER 01DELFLEX‐SM/ SOL 1.5% DEX GENERIC TIER 01DELFLEX‐SM/ SOL 2.5% DEX GENERIC TIER 01DELFLEX‐SM/ SOL 4.25 DEX BRAND TIER 03DIANEAL SOL LOW CALC BRAND TIER 03DIANEAL PD‐2 SOL 1.5% DEX 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= DrugExclusion164