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 StatusMIOTICS MIOCHOL‐E SOL 1:100 BRAND TIER 03MIOSTAT INJ 0.01% OP BRAND TIER 03PHOSPHOLINE SOL 0.125%OP BRAND TIER 02PILOCARPINE SOL 1% OP GENERIC TIER 01PILOCARPINE SOL 2% OP GENERIC TIER 01PILOCARPINE SOL 4% OP GENERIC TIER 01PILOPINE HS GEL 4% OP BRAND TIER 02MONOAMINE OXIDASE B INHIBITORS AZILECT TAB 0.5MG BRAND TIER 02AZILECT TAB 1MG BRAND TIER 02ELDEPRYL CAP 5MG Brand‐O TIER 03 PAEMSAM DIS 12MG/24H BRAND TIER 03EMSAM DIS 6MG/24HR BRAND TIER 03EMSAM DIS 9MG/24HR BRAND TIER 03SELEGILINE CAP 5MG GENERIC TIER 01SELEGILINE TAB 5MG GENERIC TIER 01ZELAPAR TAB 1.25MG BRAND TIER 03MONOAMINE OXIDASE INHIBITORS MARPLAN TAB 10MG BRAND TIER 03NARDIL TAB 15MG Brand‐O TIER 03 PAPARNATE TAB 10MG Brand‐O TIER 03 PAPHENELZINE TAB 15MG GENERIC TIER 01TRANYLCYPROM TAB 10MG GENERIC TIER 01MONOBACTAMS AZACTAM INJ 1GM Brand‐O TIER 03 PAAZACTAM INJ 2GM Brand‐O TIER 03 PAAZACTAM/DEX INJ 1GM BRAND TIER 03AZACTAM/DEX INJ 2GM BRAND TIER 03AZTREONAM INJ 1GM GENERIC TIER 01AZTREONAM INJ 2GM GENERIC TIER 01CAYSTON INH 75MG BRAND TIER 02MONOCLONAL ANTIBODIES SYNAGIS INJ 100MG/ML BRAND TIER 02 PA QL SPSYNAGIS INJ 50MG BRAND TIER 02 PA QL SPMOUTHWASHES AND GARGLES DOBELLS SOL GENERIC TIER 01MUCOLYTIC AGENTS HYPERSAL NEB 3.5% BRAND TIER 99 DENEBUSAL NEB 6% BRAND TIER 99 DEPULMOZYME SOL 1MG/ML BRAND TIER 02 SPSODIUM CHLOR NEB 10% GENERIC TIER 99 DESODIUM CHLOR NEB 3% GENERIC TIER 99 DESODIUM CHLOR NEB 7% GENERIC TIER 99 DEHYPER‐SAL NEB 7% Brand‐O TIER 99 PA DEHYPERSAL NEB 7% Brand‐O TIER 99 PA DEKey: 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= DrugExclusion178