BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNUCLEOSIDE,NUCLEOTIDE REV.TRNSCRIP.INHIB RETROVIR TAB 300MG Brand‐O TIER 03 PASTAVUDINE CAP 15MG GENERIC TIER 01STAVUDINE CAP 20MG GENERIC TIER 01STAVUDINE CAP 30MG GENERIC TIER 01STAVUDINE CAP 40MG GENERIC TIER 01STAVUDINE SOL 1MG/ML GENERIC TIER 01TRIZIVIR TAB BRAND TIER 02TRUVADA TAB BRAND TIER 02VIDEX SOL 2GM BRAND TIER 02VIDEX SOL 4GM BRAND TIER 02VIDEX EC CAP 125MG Brand‐O TIER 03 PAVIDEX EC CAP 200MG Brand‐O TIER 03 PAVIDEX EC CAP 250MG Brand‐O TIER 03 PAVIDEX EC CAP 400MG Brand‐O TIER 03 PAVIREAD POW 40MG/GM BRAND TIER 02VIREAD TAB 150MG BRAND TIER 02VIREAD TAB 200MG BRAND TIER 02VIREAD TAB 250MG BRAND TIER 02VIREAD TAB 300MG BRAND TIER 02ZERIT CAP 15MG Brand‐O TIER 03 PAZERIT CAP 20MG Brand‐O TIER 03 PAZERIT CAP 30MG Brand‐O TIER 03 PAZERIT CAP 40MG Brand‐O TIER 03 PAZERIT SOL 1MG/ML Brand‐O TIER 02 PAZIAGEN SOL 20MG/ML BRAND TIER 02ZIAGEN TAB 300MG Brand‐O TIER 03 PAZIDOVUDINE CAP 100MG GENERIC TIER 01ZIDOVUDINE SYP 50MG/5ML GENERIC TIER 01ZIDOVUDINE TAB 300MG GENERIC TIER 01NUCLEOSIDES AND NUCLEOTIDES ACYCLOVIR CAP 200MG GENERIC TIER 01ACYCLOVIR SUS 200/5ML GENERIC TIER 01ACYCLOVIR TAB 400MG GENERIC TIER 01ACYCLOVIR TAB 800MG GENERIC TIER 01ACYCLOVIR NA INJ 1000MG GENERIC TIER 01ACYCLOVIR NA INJ 500MG GENERIC TIER 01ACYCLOVIR NA INJ 50MG/ML GENERIC TIER 01BARACLUDE SOL .05MG/ML BRAND TIER 02BARACLUDE TAB 0.5MG BRAND TIER 02BARACLUDE TAB 1MG BRAND TIER 02Key: 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= DrugExclusion194
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNUCLEOSIDES AND NUCLEOTIDES COPEGUS TAB 200MG Brand‐O TIER 03 PA SPCYTOVENE INJ 500MG Brand‐O TIER 03 PAFAMCICLOVIR TAB 125MG GENERIC TIER 01FAMCICLOVIR TAB 250MG GENERIC TIER 01FAMCICLOVIR TAB 500MG GENERIC TIER 01FAMVIR TAB 125MG Brand‐O TIER 03 PAFAMVIR TAB 250MG Brand‐O TIER 03 PAFAMVIR TAB 500MG Brand‐O TIER 03 PAGANCICLOVIR INJ 500MG GENERIC TIER 01HEPSERA TAB 10MG BRAND TIER 02REBETOL CAP 200MG Brand‐O TIER 03 PA SPREBETOL SOL 40MG/ML BRAND TIER 03 SPRIBAPAK MIS 600/DAY BRAND TIER 02 PA SPRIBAPAK PAK 1000/DAY BRAND TIER 03 PA SPRIBAPAK PAK 1200/DAY GENERIC TIER 01 PA SPRIBAPAK PAK 800/DAY GENERIC TIER 01 PA SPRIBASPHERE CAP 200MG GENERIC TIER 01 SPRIBASPHERE TAB 200MG GENERIC TIER 01 SPRIBASPHERE TAB 400MG GENERIC TIER 01 PA SPRIBASPHERE TAB 600MG GENERIC TIER 01 PA SPRIBATAB PAK 1000/DAY GENERIC TIER 01 PA SPRIBATAB TAB 1200/DAY GENERIC TIER 01 PA SPRIBATAB TAB 800/DAY GENERIC TIER 01 PA SPRIBAVIRIN CAP 200MG GENERIC TIER 01 SPRIBAVIRIN TAB 200MG GENERIC TIER 01 SPTYZEKA TAB 600MG BRAND TIER 03VALACYCLOVIR TAB 1GM GENERIC TIER 01VALACYCLOVIR TAB 500MG GENERIC TIER 01VALCYTE SOL 50MG/ML BRAND TIER 03VALCYTE TAB 450MG BRAND TIER 02VALTREX TAB 1GM Brand‐O TIER 03 PAVALTREX TAB 500MG Brand‐O TIER 03 PAVIRAZOLE INH 6GM BRAND TIER 03VISTIDE INJ 75MG/ML BRAND TIER 03ZOVIRAX CAP 200MG Brand‐O TIER 03 PAZOVIRAX SUS 200/5ML Brand‐O TIER 03 PAZOVIRAX TAB 400MG Brand‐O TIER 03 PAZOVIRAX TAB 800MG Brand‐O TIER 03 PAOCULAR DISORDERS AK‐FLUOR INJ 10% OP 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= DrugExclusion195
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BMC HealthNet Plan Drug List - Comm
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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