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 OXYCONTIN TAB 40MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 60MG CR BRAND TIER 02 PA QLOXYCONTIN TAB 80MG CR BRAND TIER 02 PA QLOXYMORPHONE TAB 15MG ER GENERIC TIER 01 PA QLOXYMORPHONE TAB 7.5MG ER GENERIC TIER 01 PA QLOXYMORPHONE TAB HCL 10MG GENERIC TIER 01 PAOXYMORPHONE TAB HCL 5MG GENERIC TIER 01 PAPERCOCET TAB 10‐325MG Brand‐O TIER 03 PA QLPERCOCET TAB 10‐650MG Brand‐O TIER 03 PA QLPERCOCET TAB 2.5‐325 Brand‐O TIER 03 PA QLPERCOCET TAB 5‐325MG Brand‐O TIER 03 PA QLPERCOCET TAB 7.5‐325M Brand‐O TIER 03 PA QLPERCOCET TAB 7.5‐500 Brand‐O TIER 03 PA QLPERCODAN TAB Brand‐O TIER 03 PA QLPRIMLEV TAB 10‐300MG BRAND TIER 03 QLPRIMLEV TAB 5‐300MG BRAND TIER 03 QLPRIMLEV TAB 7.5‐300 BRAND TIER 03 QLREPREXAIN TAB 10‐200MG GENERIC TIER 01REPREXAIN TAB 2.5‐200 BRAND TIER 03REPREXAIN TAB 5‐200MG Brand‐O TIER 03 PAROXICET SOL 5‐325/5 BRAND TIER 03ROXICET TAB 5‐325MG GENERIC TIER 01 QLROXICET TAB 5‐500MG BRAND TIER 03 QLROXICODONE TAB 15MG Brand‐O TIER 03 PAROXICODONE TAB 30MG Brand‐O TIER 03 PAROXICODONE TAB 5MG Brand‐O TIER 03 PARYBIX ODT TAB 50MG BRAND TIER 03 PARYZOLT TAB 100MG Brand‐O TIER 03 PARYZOLT TAB 200MG Brand‐O TIER 03 PARYZOLT TAB 300MG Brand‐O TIER 03 PASTAGESIC CAP 5‐500MG GENERIC TIER 01SUBLIMAZE INJ 0.05MG/1 Brand‐O TIER 03 PASUBSYS SPR 100MCG BRAND TIER 03SUBSYS SPR 1200MCG BRAND TIER 03SUBSYS SPR 1600MCG BRAND TIER 03SUBSYS SPR 200MCG BRAND TIER 03SUBSYS SPR 400MCG BRAND TIER 03SUBSYS SPR 600MCG BRAND TIER 03SUBSYS SPR 800MCG 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= DrugExclusion204