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 StatusMUCOLYTIC AGENTS SOD CHLORIDE NEB 0.9% GENERIC TIER 99 DEMULTIVITAMIN PREPARATIONS ACD/FLUORIDE DRO 0.25MG GENERIC TIER 01ADRENAL C TAB FORMULA BRAND TIER 03ADVANCED MIS AM/PM BRAND TIER 03AP‐ZEL TAB BRAND TIER 03ATABEX TAB PRENATAL BRAND TIER 03ATABEX EC TAB BRAND TIER 03BACMIN TAB BRAND TIER 03BAL‐CARE MIS DHA BRAND TIER 03BAL‐CARE DHA MIS ESSNTIAL BRAND TIER 03BIOCEL TAB GENERIC TIER 01B‐NEXA TAB BRAND TIER 03BP FOLINATAL TAB PLUS B GENERIC TIER 01BP MULTINATL CHW PLUS GENERIC TIER 01BP MULTINATL TAB PLUS GENERIC TIER 01B‐PLEX TAB GENERIC TIER 01 PAB‐PLEX PLUS TAB GENERIC TIER 01CAROMEGA TAB Brand‐O TIER 03 PACAVAN TAB PRENATAL GENERIC TIER 01CAVAN ONE CAP OMEGA GENERIC TIER 01CAVAN‐ALPHA KIT BRAND TIER 03CAVAN‐EC SOD MIS DHA GENERIC TIER 01CAVAN‐FOLATE MIS DHA BRAND TIER 03CAVAN‐FOLATE TAB OB BRAND TIER 03 PACITRANATAL CAP HARMONY BRAND TIER 03CITRANATAL MIS 90 DHA BRAND TIER 03CITRANATAL MIS B‐CALM BRAND TIER 03CITRANATAL PAK ASSURE BRAND TIER 03CITRANATAL PAK DHA BRAND TIER 03CITRANATAL TAB RX BRAND TIER 03COD LIVER OIL GENERIC TIER 01COMPLETE NAT PAK DHA GENERIC TIER 01COMPLETENATE CHW GENERIC TIER 01COMPLETE‐RF TAB PRENATAL BRAND TIER 03CO‐NATAL FA TAB 29‐1MG GENERIC TIER 01 PACONCEPT DHA CAP BRAND TIER 03CONCEPT OB CAP BRAND TIER 03CORENATE‐DHA MIS BRAND TIER 03CORVITA TAB GENERIC TIER 01Key: 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= DrugExclusion179