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 ZATEAN‐CH CAP BRAND TIER 03ZATEAN‐PN CAP DHA BRAND TIER 03ZATEAN‐PN CAP PLUS BRAND TIER 03ZATEAN‐PN TAB BRAND TIER 03ZINGIBER TAB BRAND TIER 03SUPPORT‐500 CAP BRAND TIER 99 DEPROTECT CAP CARDIO BRAND TIER 99 DEOB COMPLETE CAP PETITE BRAND TIER 03VIRT‐SELECT CAP BRAND TIER 03UDAMIN TAB BRAND TIER 99 DEUDAMIN SP TAB BRAND TIER 99 DETL‐FLUORIVIT CHW BRAND TIER 03NATACHEW CHW BRAND TIER 03VITA‐MIN CAP GENERIC TIER 01MYASTHENIA GRAVIS ENLON INJ 150/15ML BRAND TIER 03MYDRIATICS AK‐PENTOLATE SOL 1% OP GENERIC TIER 01ATROPIN‐CARE SOL 1% OP GENERIC TIER 01ATROPINE SUL OIN 1% OP GENERIC TIER 01ATROPINE SUL SOL 1% OP GENERIC TIER 01CYCLOGYL SOL 0.5% OP BRAND TIER 03CYCLOGYL SOL 1% OP Brand‐O TIER 03 PACYCLOGYL SOL 2% OP Brand‐O TIER 03 PACYCLOMYDRIL SOL OP BRAND TIER 03CYCLOPENTOL SOL 1% OP GENERIC TIER 01CYCLOPENTOL SOL 2% OP GENERIC TIER 01CYLATE SOL 1% OP GENERIC TIER 01HOMATROPAIRE SOL 5% OP GENERIC TIER 01HOMATROPINE SOL 5% OP GENERIC TIER 01ISO ATROPINE SOL 1% OP Brand‐O TIER 03 PAISO HOMATROP SOL 2% OP BRAND TIER 03ISO HOMATROP SOL 5% OP Brand‐O TIER 03 PAISO HYOSCINE SOL 0.25% OP BRAND TIER 03MYDRAL SOL 0.5% OP GENERIC TIER 01MYDRAL SOL 1% OP GENERIC TIER 01MYDRIACYL SOL 1% OP Brand‐O TIER 03 PATROPICAMIDE SOL 0.5% OP GENERIC TIER 01TROPICAMIDE SOL 1% OP GENERIC TIER 01NATURAL PENICILLINS BICILLIN C‐R INJ 1200000 BRAND TIER 03BICILLIN C‐R INJ 900/300 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= DrugExclusion188