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 StatusLOCAL ANESTHETICS (PARENTERAL) BASIC BIOPSY KIT 20GX1.5" BRAND TIER 03BONE MARROW KIT 16G BRAND TIER 03BONE MARROW KIT 16GX2" BRAND TIER 03BONE MARROW KIT BIOPSY BRAND TIER 03BUPIVACAINE INJ 0.25% GENERIC TIER 01BUPIVACAINE INJ 0.5% GENERIC TIER 01BUPIVACAINE INJ 0.75% GENERIC TIER 01BUPIVACAINE INJ SPINAL GENERIC TIER 01BUPIVACAINE/ INJ EPI 0.25 GENERIC TIER 01BUPIVACAINE/ INJ EPI 0.5% GENERIC TIER 01CARBOCAINE INJ 1% Brand‐O TIER 03 PACARBOCAINE INJ 1% PF Brand‐O TIER 03 PACARBOCAINE INJ 1.5% PF Brand‐O TIER 03 PACARBOCAINE INJ 2% Brand‐O TIER 03 PACARBOCAINE INJ 2% PF Brand‐O TIER 03 PACHLOROPROC INJ 2% GENERIC TIER 01CHLOROPROC INJ 3% GENERIC TIER 01DUOCAINE INJ BRAND TIER 03EXPAREL INJ 1.3% BRAND TIER 03LIDO/DEXTROS INJ 5‐7.5% GENERIC TIER 01LIDO/EPI INJ 0.5% GENERIC TIER 01LIDO/EPI INJ 1.5% GENERIC TIER 01LIDO/EPI INJ 2% GENERIC TIER 01LIDO/EPI 1%‐ INJ 1:100000 GENERIC TIER 01LIDOCAINE INJ 0.5% GENERIC TIER 01LIDOCAINE INJ 1% GENERIC TIER 01LIDOCAINE INJ 1.5% GENERIC TIER 01LIDOCAINE INJ 2% GENERIC TIER 01LIDOCAINE INJ 4% GENERIC TIER 01MARCAINE INJ 0.25% Brand‐O TIER 03 PAMARCAINE INJ 0.5% Brand‐O TIER 03 PAMARCAINE INJ 0.75% Brand‐O TIER 03 PAMARCAINE INJ SPINAL Brand‐O TIER 03 PAMARCAINE/EPI INJ 0.25% Brand‐O TIER 03 PAMARCAINE/EPI INJ 0.5% Brand‐O TIER 03 PAMEPIVACAINE INJ 3% GENERIC TIER 01NAROPIN INJ 10MG/ML BRAND TIER 03NAROPIN INJ 2MG/ML BRAND TIER 03NAROPIN INJ 5MG/ML 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= DrugExclusion171