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 SE‐PLETE DHA CAP GENERIC TIER 01SE‐TAN DHA CAP GENERIC TIER 01SETON ET‐EC PAK GENERIC TIER 01SETONET PAK GENERIC TIER 01SIDEROL LIQ GENERIC TIER 01SIDEROL TAB GENERIC TIER 01STROVITE TAB Brand‐O TIER 03 PASTROVITE TAB ADVANCE Brand‐O TIER 03 PASTROVITE FOR SYP BRAND TIER 03STROVITE FOR TAB GENERIC TIER 01STROVITE ONE TAB BRAND TIER 03STROVITE PLU TAB GENERIC TIER 01SUPERVITE LIQ BRAND TIER 03SUPERVITE EC TAB BRAND TIER 03SUPPORT LIQ BRAND TIER 03SYNAGEX CAP 1.25MG BRAND TIER 03SYNATEK CAP BRAND TIER 03TANDEM DHA CAP BRAND TIER 03TANDEM OB CAP BRAND TIER 03TARON EC PAK CALCIUM GENERIC TIER 01TARON‐BC MIS BRAND TIER 03TARON‐C DHA CAP BRAND TIER 03TARON‐DUO EC PAK BRAND TIER 03TARON‐EC CAL TAB 28‐1MG GENERIC TIER 01TARON‐PREX CAP GENERIC TIER 01THEROBEC TAB GENERIC TIER 01 PATL G‐FOL OS TAB BRAND TIER 03TL NICOTINAM TAB IDE GENERIC TIER 01TL‐ASSURE CAP ONE BRAND TIER 03TL‐ASSURE+ MIS DHA BRAND TIER 03TL‐SELECT CAP BRAND TIER 03TRI PRENATAL CAP DHA ONE BRAND TIER 03TRI RX TAB GENERIC TIER 01TRIADVANCE TAB GENERIC TIER 01TRICARE TAB PRENATAL GENERIC TIER 01 PATRICARE DHA CAP 301 BRAND TIER 03TRIMESIS RX TAB GENERIC TIER 01TRINATAL TAB ULTRA BRAND TIER 03TRINATAL GT TAB 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= DrugExclusion185