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 DILAUDID INJ 2MG/ML Brand‐O TIER 03 PADILAUDID INJ 4MG/ML Brand‐O TIER 03 PADILAUDID TAB 2MG Brand‐O TIER 03 PADILAUDID TAB 4MG Brand‐O TIER 03 PADILAUDID TAB 8MG Brand‐O TIER 03 PADILAUDID‐5 LIQ 1MG/ML Brand‐O TIER 03 PADILAUDID‐HP INJ 10MG/ML Brand‐O TIER 03 PADILAUDID‐HP INJ 250MG BRAND TIER 03DOLOPHINE TAB 10MG Brand‐O TIER 03 PADOLOPHINE TAB 5MG Brand‐O TIER 03 PADURAGESIC DIS 100MCG/H Brand‐O TIER 03 PA QLDURAGESIC DIS 12MCG/HR Brand‐O TIER 03 PA QLDURAGESIC DIS 25MCG/HR Brand‐O TIER 03 PA QLDURAGESIC DIS 50MCG/HR Brand‐O TIER 03 PA QLDURAGESIC DIS 75MCG/HR Brand‐O TIER 03 PA QLDURAMORPH INJ 0.5MG/ML GENERIC TIER 01DURAMORPH INJ 1MG/ML GENERIC TIER 01ENDOCET TAB 10‐325MG GENERIC TIER 01 QLENDOCET TAB 10‐650MG GENERIC TIER 01 QLENDOCET TAB 5‐325MG GENERIC TIER 01 QLENDOCET TAB 7.5‐325M GENERIC TIER 01 QLENDOCET TAB 7.5‐500M GENERIC TIER 01 QLENDODAN TAB GENERIC TIER 01 QLEXALGO TAB 12MG BRAND TIER 03 PA QLEXALGO TAB 16MG BRAND TIER 03 PA QLEXALGO TAB 32MG BRAND TIER 03 PAEXALGO TAB 8MG BRAND TIER 03 PA QLFENTANYL DIS 100MCG/H GENERIC TIER 01 QLFENTANYL DIS 12MCG/HR GENERIC TIER 01 QLFENTANYL DIS 25MCG/HR GENERIC TIER 01 QLFENTANYL DIS 50MCG/HR GENERIC TIER 01 QLFENTANYL DIS 75MCG/HR GENERIC TIER 01 QLFENTANYL CIT INJ 0.05MG/1 GENERIC TIER 01 PAFENTANYL CIT INJ 1000MCG GENERIC TIER 01 PAFENTANYL CIT INJ 100MCG GENERIC TIER 01 PAFENTANYL CIT INJ 2500MCG GENERIC TIER 01 PAFENTANYL CIT INJ 250MCG GENERIC TIER 01 PAFENTANYL OT LOZ 1200MCG GENERIC TIER 01 PA QLFENTANYL OT LOZ 1600MCG GENERIC TIER 01 PA QLKey: 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= DrugExclusion198