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 StatusANOREX.,RESPIR.,CEREBRAL STIMULANTS,MISC METHYLPHENID TAB 54MG ER GENERIC TIER 01 PA QLMETHYLPHENID TAB 5MG GENERIC TIER 01 QLMODAFINIL TAB 100MG GENERIC TIER 01 PA QLMODAFINIL TAB 200MG GENERIC TIER 01 PA QLNUVIGIL TAB 150MG BRAND TIER 03 PA QLNUVIGIL TAB 250MG BRAND TIER 03 PA QLNUVIGIL TAB 50MG BRAND TIER 03 PA QLPHENDIMETRAZ CAP 105MG ER GENERIC TIER 99 DEPHENDIMETRAZ TAB 35MG GENERIC TIER 99 DEPHENTERMINE CAP 15MG GENERIC TIER 99 DEPHENTERMINE CAP 30MG GENERIC TIER 99 DEPHENTERMINE CAP 37.5MG GENERIC TIER 99 DEPHENTERMINE TAB 37.5MG GENERIC TIER 99 DEPROVIGIL TAB 100MG Brand‐O TIER 03 PA QLPROVIGIL TAB 200MG Brand‐O TIER 03 PA QLQSYMIA CAP 11.25‐69 BRAND TIER 99 DEQSYMIA CAP 15‐92MG BRAND TIER 99 DEQSYMIA CAP 3.75‐23 BRAND TIER 99 DEQSYMIA CAP 7.5‐46MG BRAND TIER 99 DERITALIN TAB 10MG Brand‐O TIER 03 PA QLRITALIN TAB 20MG Brand‐O TIER 03 PA QLRITALIN TAB 20MG SR Brand‐O TIER 03 PA QLRITALIN TAB 5MG Brand‐O TIER 03 PA QLRITALIN LA CAP 10MG BRAND TIER 03 QLRITALIN LA CAP 20MG Brand‐O TIER 03 PA QLRITALIN LA CAP 30MG Brand‐O TIER 03 PA QLRITALIN LA CAP 40MG Brand‐O TIER 03 PA QLSENTRAMODAFI PAK AM‐100 BRAND TIER 03SUPRENZA TAB 15MG BRAND TIER 99 DESUPRENZA TAB 30MG BRAND TIER 99 DEADIPEX‐P CAP 37.5MG Brand‐O TIER 99 PA DEBONTRIL PDM TAB 35MG Brand‐O TIER 99 PA DEADIPEX‐P TAB 37.5MG Brand‐O TIER 99 PA DEBONTRIL SR CAP 105MG Brand‐O TIER 99 PA DEAMMONIA AROM INH GENERIC TIER 01ANTHELMINTICS ALBENZA TAB 200MG BRAND TIER 02BILTRICIDE TAB 600MG BRAND TIER 02MEBENDAZOLE CHW 100MG GENERIC TIER 01SKLICE LOT 0.5% BRAND TIER 03Key: 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= DrugExclusion20