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 TRINATAL RX TAB 1 GENERIC TIER 01 PATRINATE TAB GENERIC TIER 01 PATRIPHROCAPS CAP GENERIC TIER 01TRIVEEN‐DUO PAK DHA BRAND TIER 03TRIVEEN‐ONE CAP BRAND TIER 03TRIVEEN‐PRX CAP RNF BRAND TIER 03TRIVEEN‐TEN TAB BRAND TIER 03TRIVEEN‐U CAP BRAND TIER 03TRI‐VI‐FLOR SUS 0.25/ML BRAND TIER 03TRI‐VI‐FLOR SUS 0.5MG/ML BRAND TIER 03TRI‐VIT/FE DRO /FL 0.25 GENERIC TIER 01TRI‐VIT/FL DRO 0.25MG GENERIC TIER 01TRI‐VIT/FL DRO 0.5MG GENERIC TIER 01TRI‐VIT/FLUO DRO 0.25MG GENERIC TIER 01TRI‐VIT/FLUO DRO 0.5MG GENERIC TIER 01TRI‐VITA/FL DRO 0.25MG GENERIC TIER 01TRI‐ZEL TAB BRAND TIER 03TRUST NATAL PAK DHA GENERIC TIER 01ULTIMATE OB MIS DHA BRAND TIER 03ULTIMATECARE CAP ONE GENERIC TIER 01ULTIMATECARE CAP ONE NF GENERIC TIER 01ULTIMATECARE MIS ADVANTAG BRAND TIER 03ULTIMATECARE MIS COMBO BRAND TIER 03ULTRA TABS TAB GENERIC TIER 01UROSEX TAB GENERIC TIER 99 DEV‐C FORTE CAP GENERIC TIER 01VEMAVITE‐ CAP PRX 2 BRAND TIER 03VENA‐BAL MIS DHA BRAND TIER 03VENATAL COMP MIS DHA BRAND TIER 03VENATAL‐FA TAB BRAND TIER 03 PAVICAP FORTE CAP GENERIC TIER 01VIC‐FORTE CAP GENERIC TIER 01VINACAL TAB BRAND TIER 03VINATE AZ TAB GENERIC TIER 01VINATE AZ EX TAB BRAND TIER 02VINATE C TAB GENERIC TIER 01VINATE CAL TAB BRAND TIER 03VINATE CARE CHW GENERIC TIER 01VINATE GT 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= DrugExclusion186