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 StatusMULTIVITAMIN PREPARATIONS LACTOCAL‐F TAB BRAND TIER 03 PALEVOMEFOLATE CAP DHA BRAND TIER 02LEVOMEFOLATE MIS BRAND TIER 03L‐METHYLFOLA CAP PNV DHA BRAND TIER 02LYSIPLEX TAB PLUS GENERIC TIER 01M.V.I PEDIAT INJ BRAND TIER 03M.V.I. ADULT INJ BRAND TIER 03M.V.I‐12 W/O INJ VIT K BRAND TIER 03MACNATAL CN CAP DHA GENERIC TIER 01MARNATAL‐F CAP BRAND TIER 03MARNATAL‐F MIS PLUS DUO BRAND TIER 03MAXINATE TAB BRAND TIER 03MULTICHEW CHW BRAND TIER 03MULTI‐VIT/FE DRO /FL 0.25 GENERIC TIER 01MULTIVIT/FL CHW 0.25MG GENERIC TIER 01MULTIVIT/FL CHW 0.5MG GENERIC TIER 01MULTIVIT/FL CHW 1MG GENERIC TIER 01MULTI‐VIT/FL CHW 0.25MG GENERIC TIER 01MULTI‐VIT/FL CHW 0.5MG GENERIC TIER 01MULTI‐VIT/FL CHW 1MG GENERIC TIER 01MULTI‐VIT/FL DRO /FE 0.25 GENERIC TIER 01MULTI‐VIT/FL DRO 0.25MG GENERIC TIER 01MULTI‐VIT/FL DRO 0.5MG/ML GENERIC TIER 01MULT‐VIT/FL CHW 0.5MG GENERIC TIER 01MVC‐FLUORIDE CHW 0.25MG GENERIC TIER 01MVC‐FLUORIDE CHW 0.5MG GENERIC TIER 01MVC‐FLUORIDE CHW 1MG GENERIC TIER 01M‐VIT TAB 27‐1MG GENERIC TIER 01 PAMYKIDZ IRON SUS FL BRAND TIER 03MYNATAL CAP BRAND TIER 03MYNATAL TAB GENERIC TIER 01MYNATAL TAB ADVANCE GENERIC TIER 01MYNATAL PLUS TAB GENERIC TIER 01 PAMYNATAL‐Z TAB GENERIC TIER 01 PAMYNATE 90 TAB PLUS GENERIC TIER 01MYNEPHROCAPS CAP GENERIC TIER 01NATA KOMPLET TAB 25‐1MG BRAND TIER 03NATAFORT TAB BRAND TIER 03NATALVIT TAB 75‐1MG BRAND 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= DrugExclusion181