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 StatusNATURAL PENICILLINS BICILLIN L‐A INJ 1200000 BRAND TIER 03BICILLIN L‐A INJ 2400000 BRAND TIER 03BICILLIN L‐A INJ 600000 BRAND TIER 03PEN G PROC INJ 600000 GENERIC TIER 01PEN G SOD INJ 5000000 GENERIC TIER 01PENICILL GK/ INJ DEX 1MU GENERIC TIER 01PENICILL GK/ INJ DEX 2MU GENERIC TIER 01PENICILL GK/ INJ DEX 3MU GENERIC TIER 01PENICILLN GK INJ 20MU GENERIC TIER 01PENICILLN GK INJ 5MU GENERIC TIER 01PENICILLN VK SOL 125/5ML GENERIC TIER 01PENICILLN VK SOL 250/5ML GENERIC TIER 01PENICILLN VK TAB 250MG GENERIC TIER 01PENICILLN VK TAB 500MG GENERIC TIER 01PFIZERPEN‐G INJ 20MU Brand‐O TIER 03 PAPFIZERPEN‐G INJ 5MU GENERIC TIER 01NEURAMINIDASE INHIBITORS RELENZA MIS DISKHALE BRAND TIER 02 QLTAMIFLU CAP 30MG BRAND TIER 02 QLTAMIFLU CAP 45MG BRAND TIER 02 QLTAMIFLU CAP 75MG BRAND TIER 02 QLTAMIFLU SUS 12MG/ML BRAND TIER 02 QLTAMIFLU SUS 6MG/ML BRAND TIER 02 QLNEUROMUSCULAR BLOCKING AGENTS ANECTINE INJ 20MG/ML Brand‐O TIER 03 PAATRACURIUM INJ 10MG/ML GENERIC TIER 01CISATRACURIU INJ 10MG/ML GENERIC TIER 01CISATRACURIU INJ 2MG/ML GENERIC TIER 01NIMBEX INJ 10MG/ML Brand‐O TIER 03 PANIMBEX INJ 2MG/ML Brand‐O TIER 03 PAPANCURONIUM INJ 1MG/ML GENERIC TIER 01PANCURONIUM INJ 2MG/ML GENERIC TIER 01QUELICIN INJ ‐1000 BRAND TIER 03QUELICIN INJ 20MG/ML Brand‐O TIER 03 PAROCURONIUM INJ 100MG/10 GENERIC TIER 01ROCURONIUM INJ 10MG/ML GENERIC TIER 01ROCURONIUM INJ 50MG/5ML GENERIC TIER 01TIZANIDINE KIT COMFORT BRAND TIER 03VECURONIUM INJ 10MG GENERIC TIER 01VECURONIUM INJ 20MG GENERIC TIER 01ZEMURON INJ 10MG/ML 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= DrugExclusion189