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 NATELLE ONE CAP BRAND TIER 03NATELLE‐EZ TAB BRAND TIER 03 PANEEVO PAK BRAND TIER 02NEEVO DHA CAP BRAND TIER 02NEPHPLEX RX TAB BRAND TIER 03NEPHROCAPS CAP Brand‐O TIER 03 PANEPHROCAPS TAB QT BRAND TIER 03NEPHRONEX TAB 1MG GENERIC TIER 01 PANEPHRO‐VITE TAB RX Brand‐O TIER 03 PANESTABS TAB BRAND TIER 03NESTABS DHA PAK BRAND TIER 03NEURODEP SOL GENERIC TIER 01NEXA PLUS CAP BRAND TIER 03NEXA SELECT CAP BRAND TIER 03NICAZEL TAB BRAND TIER 03NICOMIDE TAB BRAND TIER 03NICOTINAMIDE TAB ZN/CU/FA GENERIC TIER 01NUTRICAP TAB GENERIC TIER 01NUTRIFAC ZX TAB GENERIC TIER 01NUTRI‐TAB OB MIS + DHA BRAND TIER 03NUTRI‐TAB OB TAB 32‐1MG BRAND TIER 03NUTRIVIT LIQ 800‐15‐1 BRAND TIER 03OB COMPLETE CAP 400 BRAND TIER 03OB COMPLETE CAP ONE BRAND TIER 03OB COMPLETE CAP WITH DHA BRAND TIER 03OB COMPLETE CHW BRAND TIER 03OB COMPLETE TAB BRAND TIER 03OB COMPLETE TAB PREMIER BRAND TIER 03OB COMPLETE/ CAP DHA BRAND TIER 03OB‐NATAL ONE CAP 20‐7‐1MG GENERIC TIER 01OB‐NATAL ONE CAP 27‐1MG GENERIC TIER 01OBSTETRIX PAK DHA BRAND TIER 03OBSTETRIX EC TAB GENERIC TIER 01O‐CAL TAB PRENATAL BRAND TIER 03 PAO‐CAL FA TAB BRAND TIER 03 PAPAIRE OB MIS BRAND TIER 03PNV OB+DHA PAK BRAND TIER 03PNV‐DHA CAP GENERIC TIER 01PNV‐DHA CAP DOCUSATE 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= DrugExclusion182