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) NAROPIN INJ 7.5MG/ML BRAND TIER 03NESACAINE INJ 1% BRAND TIER 03NESACAINE INJ 2% Brand‐O TIER 03 PANESACAINE INJ ‐MPF 2% Brand‐O TIER 03 PANESACAINE INJ ‐MPF 3% Brand‐O TIER 03 PAPNEUMOTHORX KIT TRAY 8FR BRAND TIER 03POLOCAINE INJ 1% GENERIC TIER 01POLOCAINE INJ 2% GENERIC TIER 01POLOCAINE INJ ‐MPF 1% GENERIC TIER 01POLOCAINE INJ MPF 1.5% GENERIC TIER 01POLOCAINE INJ ‐MPF 2% GENERIC TIER 01PONTOCAINE INJ 1% Brand‐O TIER 03 PAPONTOCAINE INJ 20MG BRAND TIER 03PROCAINE HCL CRY GENERIC TIER 99 DEPUDEND/LOCAL KIT 1% LIDO GENERIC TIER 01SENSORCAINE INJ 0.25% GENERIC TIER 01SENSORCAINE INJ 0.5% GENERIC TIER 01SENSORCAINE INJ MPF 0.5% GENERIC TIER 01SENSORCAINE INJ MPF SPIN GENERIC TIER 01SENSORCAINE INJ ‐MPF/EPI BRAND TIER 03SENSORCAINE INJ ‐MPF/EPI GENERIC TIER 01SENSORCAINE INJ MPF0.25% GENERIC TIER 01SENSORCAINE INJ MPF0.75% GENERIC TIER 01SENSORCAINE/ INJ EPI 0.25 GENERIC TIER 01SENSORCAINE/ INJ EPI 0.5% GENERIC TIER 01SPINAL/EPIDU KIT CL CATH BRAND TIER 03SPINAL/EPIDU KIT OPN CATH BRAND TIER 03TETRACAINE INJ 1% GENERIC TIER 01XYLO/EPI INJ 0.5% Brand‐O TIER 03 PAXYLO/EPI INJ 2% Brand‐O TIER 03 PAXYLO/EPI 1%‐ INJ 1:100000 Brand‐O TIER 03 PAXYLOCAINE INJ 0.5% Brand‐O TIER 03 PAXYLOCAINE INJ 1% Brand‐O TIER 03 PAXYLOCAINE INJ 2% Brand‐O TIER 03 PAXYLOCAINE INJ MPF 0.5% Brand‐O TIER 03 PAXYLOCAINE INJ ‐MPF 1% Brand‐O TIER 03 PAXYLOCAINE INJ MPF 1.5% Brand‐O TIER 03 PAXYLOCAINE INJ ‐MPF 2% Brand‐O TIER 03 PAXYLOCAINE INJ ‐MPF 4% Brand‐O TIER 03 PAKey: 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= DrugExclusion172