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 StatusOPIATE AGONISTS HYDROMORPHON INJ 2MG/ML GENERIC TIER 01HYDROMORPHON INJ 4MG/ML GENERIC TIER 01HYDROMORPHON INJ 500/50ML GENERIC TIER 01HYDROMORPHON INJ 50MG/5ML GENERIC TIER 01HYDROMORPHON LIQ 1MG/ML GENERIC TIER 01HYDROMORPHON SUP 3MG GENERIC TIER 01HYDROMORPHON TAB 2MG GENERIC TIER 01HYDROMORPHON TAB 4MG GENERIC TIER 01HYDROMORPHON TAB 8MG GENERIC TIER 01IBUDONE TAB 10‐200MG Brand‐O TIER 03 PAIBUDONE TAB 5‐200MG GENERIC TIER 01INFUMORPH INJ 10MG/ML BRAND TIER 03INFUMORPH INJ 10MG/ML GENERIC TIER 01INFUMORPH INJ 25MG/ML BRAND TIER 03INFUMORPH INJ 25MG/ML GENERIC TIER 01KADIAN CAP 100MG CR Brand‐O TIER 03 PA QLKADIAN CAP 10MG CR BRAND TIER 03 PA QLKADIAN CAP 130MG CR BRAND TIER 03 PAKADIAN CAP 150MG CR BRAND TIER 03 PAKADIAN CAP 200MG CR BRAND TIER 03 PA QLKADIAN CAP 20MG CR Brand‐O TIER 03 PA QLKADIAN CAP 30MG CR Brand‐O TIER 03 PA QLKADIAN CAP 40MG CR BRAND TIER 03 PAKADIAN CAP 50MG CR Brand‐O TIER 03 PA QLKADIAN CAP 60MG CR Brand‐O TIER 03 PA QLKADIAN CAP 70MG CR BRAND TIER 03 PAKADIAN CAP 80MG CR Brand‐O TIER 03 PA QLLAZANDA SPR 100MCG BRAND TIER 03 PALAZANDA SPR 400MCG BRAND TIER 03 PALEVORPHANOL TAB 2MG GENERIC TIER 01LIQUICET SOL 10‐500MG BRAND TIER 03LORCET TAB 10‐650MG Brand‐O TIER 03 PALORCET PLUS TAB 7.5‐650 Brand‐O TIER 03 PALORTAB ELX 7.5‐500 Brand‐O TIER 03 PALORTAB TAB 10‐500MG Brand‐O TIER 03 PALORTAB TAB 5‐500MG Brand‐O TIER 03 PALORTAB TAB 7.5‐500 Brand‐O TIER 03 PAMAGNACET TAB 10‐400MG BRAND TIER 03 QLMAGNACET TAB 5‐400MG BRAND TIER 03 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= DrugExclusion200
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOPIATE AGONISTS MAGNACET TAB 7.5‐400 BRAND TIER 03 QLMAXIDONE TAB 10‐750MG Brand‐O TIER 03 PAMEPERIDINE INJ 100MG/ML GENERIC TIER 01MEPERIDINE INJ 10MG/ML GENERIC TIER 01MEPERIDINE INJ 25MG/ML GENERIC TIER 01MEPERIDINE INJ 50MG/ML GENERIC TIER 01MEPERIDINE SOL 50MG/5ML GENERIC TIER 01MEPERIDINE TAB 100MG GENERIC TIER 01MEPERIDINE TAB 50MG GENERIC TIER 01MEPERITAB TAB 100MG GENERIC TIER 01MEPERITAB TAB 50MG GENERIC TIER 01METHADONE CON 10MG/ML Brand‐O TIER 03 PAMETHADONE CON 10MG/ML GENERIC TIER 01METHADONE INJ 10MG/ML GENERIC TIER 01METHADONE SOL 10MG/5ML GENERIC TIER 01METHADONE SOL 5MG/5ML GENERIC TIER 01METHADONE TAB 10MG GENERIC TIER 01METHADONE TAB 40MG GENERIC TIER 01METHADONE TAB 5MG GENERIC TIER 01METHADOSE CON 10MG/ML GENERIC TIER 01METHADOSE TAB 10MG GENERIC TIER 01METHADOSE TAB 40MG GENERIC TIER 01METHADOSE SF CON 10MG/ML GENERIC TIER 01MORPHINE SUL CAP 100MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 20MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 30MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 50MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 60MG ER GENERIC TIER 01 PA QLMORPHINE SUL CAP 80MG ER GENERIC TIER 01 PA QLMORPHINE SUL INJ 0.5MG/ML GENERIC TIER 01MORPHINE SUL INJ 10/0.7ML GENERIC TIER 01MORPHINE SUL INJ 10MG/ML GENERIC TIER 01MORPHINE SUL INJ 150/30ML GENERIC TIER 01MORPHINE SUL INJ 15MG/ML GENERIC TIER 01MORPHINE SUL INJ 1MG/ML GENERIC TIER 01MORPHINE SUL INJ 25MG/ML GENERIC TIER 01MORPHINE SUL INJ 2MG/ML GENERIC TIER 01MORPHINE SUL INJ 4MG/ML GENERIC TIER 01MORPHINE SUL INJ 50MG/ML 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= DrugExclusion201
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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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