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 PRENATAL 19 CHW TAB GENERIC TIER 01PRENATAL 19 TAB GENERIC TIER 01PRENATAL AD TAB GENERIC TIER 01PRENATAL VIT TAB PLUS BRAND TIER 03 PAPRENATAL‐U CAP GENERIC TIER 01PRENATE CAP ESSENTIL BRAND TIER 02PRENATE TAB ELITE BRAND TIER 02PRENATE DHA CAP BRAND TIER 02PRENATE ELIT TAB BRAND TIER 02PRENATE MINI CAP BRAND TIER 03PRENEXA CAP BRAND TIER 03PREQUE 10 TAB BRAND TIER 03PROTECT PLUS CAP BRAND TIER 03PROTECT PLUS CAP NR BRAND TIER 03PROTECT PLUS LIQ BRAND TIER 03PROTECTBONE WAF BRAND TIER 03PROTECTIRON TAB BRAND TIER 03PROTECTNATAL TAB BRAND TIER 03PUREFE OB CAP PLUS BRAND TIER 03REAPHIRM CAP BRAND TIER 03REDICHEW CHW RX BRAND TIER 03RELNATE DHA CAP BRAND TIER 03RENAL CAP SOFTGEL GENERIC TIER 01RENALPREN CAP GENERIC TIER 01RENATABS TAB BRAND TIER 03RENA‐VITE RX TAB GENERIC TIER 01 PARENAX TAB 2.5MG BRAND TIER 03RENAX 5.5 TAB BRAND TIER 03RENO CAP GENERIC TIER 01REQ 49+ TAB BRAND TIER 03SE‐CARE CHW GENERIC TIER 01SE‐CARE TAB CONCEIVE GENERIC TIER 01SELECT‐OB CHW BRAND TIER 03SELECT‐OB+ PAK DHA BRAND TIER 03SE‐NATAL 19 CHW GENERIC TIER 01SE‐NATAL 19 TAB GENERIC TIER 01SE‐NATAL 90 TAB GENERIC TIER 01SE‐NATAL ONE TAB GENERIC TIER 01 PASENETONIC LIQ 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= DrugExclusion184