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 StatusOPIATE AGONISTS APAP/CODEINE TAB 300‐30MG GENERIC TIER 01APAP/CODEINE TAB 300‐60MG GENERIC TIER 01ASCOMP/COD CAP 30MG GENERIC TIER 01ASTRAMORPH INJ 10/10ML GENERIC TIER 01ASTRAMORPH INJ 1MG/2ML GENERIC TIER 01ASTRAMORPH INJ 2MG/2ML GENERIC TIER 01AVINZA CAP 120MG BRAND TIER 02 PA QLAVINZA CAP 30MG BRAND TIER 02 PA QLAVINZA CAP 45MG BRAND TIER 02 PA QLAVINZA CAP 60MG BRAND TIER 02 PA QLAVINZA CAP 75MG BRAND TIER 02 PA QLAVINZA CAP 90MG BRAND TIER 02 PA QLBUT/APAP/CAF CAP CODEINE GENERIC TIER 01BUT/ASA/CAF/ CAP COD 30MG GENERIC TIER 01CAPITAL/COD SUS 120‐12/5 BRAND TIER 03COCET TAB 650‐30MG BRAND TIER 03COCET PLUS TAB 650‐60MG BRAND TIER 03CODEINE PHOS INJ 30MG/2ML GENERIC TIER 01CODEINE PHOS INJ 60MG/2ML GENERIC TIER 01CODEINE SULF SOL 30MG/5ML GENERIC TIER 01CODEINE SULF TAB 15MG GENERIC TIER 01CODEINE SULF TAB 30MG GENERIC TIER 01CODEINE SULF TAB 60MG GENERIC TIER 01CO‐GESIC TAB 5‐500MG GENERIC TIER 01CONZIP CAP 100MG BRAND TIER 03CONZIP CAP 200MG BRAND TIER 03CONZIP CAP 300MG BRAND TIER 03DEMEROL INJ 100/2ML BRAND TIER 03DEMEROL INJ 100MG/ML Brand‐O TIER 03 PADEMEROL INJ 25MG/0.5 BRAND TIER 03DEMEROL INJ 25MG/ML Brand‐O TIER 03 PADEMEROL INJ 50MG/ML Brand‐O TIER 03 PADEMEROL INJ 75MG/1.5 BRAND TIER 03DEMEROL INJ 75MG/ML BRAND TIER 03DEMEROL TAB 100MG Brand‐O TIER 03 PADEMEROL TAB 50MG Brand‐O TIER 03 PADEPODUR INJ 10MG/ML BRAND TIER 03DEPODUR INJ 15/1.5ML BRAND TIER 03DILAUDID INJ 1MG/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= DrugExclusion197