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 StatusOCULAR DISORDERS ALTAFLUOR SOL 0.25‐0.4 GENERIC TIER 01BIO GLO TES 1MG OP GENERIC TIER 01FLUCAINE SOL 0.25‐0.5 GENERIC TIER 01FLUORACAINE SOL OP Brand‐O TIER 03 PAFLUORE‐BENOX SOL 0.25‐0.4 GENERIC TIER 01FLUORESCEIN INJ 10% OP GENERIC TIER 01FLUORESCEIN INJ 25% OP GENERIC TIER 01FLUORESCEIN/ SOL PROPARAC GENERIC TIER 01FLUORESCITE INJ 10% OP Brand‐O TIER 03 PAFLUORETS TES 1MG OP GENERIC TIER 01FLUOR‐I‐STRI TES 1MG OP GENERIC TIER 01FLURA‐SAFE SOL BRAND TIER 99 DEFLURESS SOL OP Brand‐O TIER 03 PAFLUROX SOL OP GENERIC TIER 01FUL‐GLO TES 0.6MG OP BRAND TIER 03FUL‐GLO TES 1MG OP GENERIC TIER 01LISSAMINE GR TES 1.5MG GENERIC TIER 01MEMBRANEBLUE SOL 0.15% BRAND TIER 99 DEPAREMYD SOL 1‐0.25% BRAND TIER 03PROP‐FLUORE SOL 0.5‐0.25 GENERIC TIER 01ROSE GLO TES 1.5MG BRAND TIER 03VISIONBLUE SOL 0.06% BRAND TIER 99 DEOPIATE AGONISTS ABSTRAL SUB 100MCG BRAND TIER 03 PAABSTRAL SUB 200MCG BRAND TIER 03 PAABSTRAL SUB 300MCG BRAND TIER 03 PAABSTRAL SUB 400MCG BRAND TIER 03 PAABSTRAL SUB 600MCG BRAND TIER 03 PAABSTRAL SUB 800MCG BRAND TIER 03 PAACTIQ LOZ 1200MCG Brand‐O TIER 03 PA QLACTIQ LOZ 1600MCG Brand‐O TIER 03 PA QLACTIQ LOZ 200MCG Brand‐O TIER 03 PA QLACTIQ LOZ 400MCG Brand‐O TIER 03 PA QLACTIQ LOZ 600MCG Brand‐O TIER 03 PA QLACTIQ LOZ 800MCG Brand‐O TIER 03 PA QLALFENTA INJ 500/ML Brand‐O TIER 03 PAALFENTANIL INJ 500/ML GENERIC TIER 01APAP/CAFF/DI TAB HYDROCOD GENERIC TIER 01APAP/CODEINE SOL 120‐12/5 GENERIC TIER 01APAP/CODEINE TAB 300‐15MG 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= DrugExclusion196