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 XODOL TAB 7.5‐300 Brand‐O TIER 03 PAXOLOX TAB 10‐500MG BRAND TIER 03 QLZAMICET SOL 10‐325MG BRAND TIER 03ZOLVIT SOL 10‐300MG BRAND TIER 03ZYDONE TAB 10‐400MG BRAND TIER 03ZYDONE TAB 5‐400MG BRAND TIER 03ZYDONE TAB 7.5‐400 BRAND TIER 03OPIATE ANTAGONISTS DEPADE TAB 50MG GENERIC TIER 01NALOXONE INJ 0.4MG/ML GENERIC TIER 01NALOXONE INJ 1MG/ML GENERIC TIER 01NALTREXONE TAB 50MG GENERIC TIER 01REVIA TAB 50MG Brand‐O TIER 03 PAVIVITROL INJ 380MG BRAND TIER 02 PA SPOPIATE PARTIAL AGONISTS BUPRENEX INJ 0.3MG/ML Brand‐O TIER 03 PABUPRENORPHIN INJ 0.3MG/ML GENERIC TIER 01 PABUPRENORPHIN SUB 2MG GENERIC TIER 01 PA QLBUPRENORPHIN SUB 8MG GENERIC TIER 01 PA QLBUTORPHANOL INJ 1MG/ML GENERIC TIER 01BUTORPHANOL INJ 2MG/ML GENERIC TIER 01BUTORPHANOL SOL 10MG/ML GENERIC TIER 01 QLBUTRANS DIS 10MCG/HR BRAND TIER 02 PABUTRANS DIS 20MCG/HR BRAND TIER 02 PABUTRANS DIS 5MCG/HR BRAND TIER 02 PANALBUPHINE INJ 10MG/ML GENERIC TIER 01NALBUPHINE INJ 20MG/ML GENERIC TIER 01PENTA/APAP TAB 25‐650MG GENERIC TIER 01PENTAZ/NALOX TAB 50‐0.5MG GENERIC TIER 01SUBOXONE MIS 2‐0.5MG BRAND TIER 02 PA QLSUBOXONE MIS 8‐2MG BRAND TIER 02 PA QLSUBOXONE SUB 2‐0.5MG BRAND TIER 03 QLSUBOXONE SUB 8‐2MG BRAND TIER 03 QLSUBUTEX SUB 2MG Brand‐O TIER 03 PA QLSUBUTEX SUB 8MG Brand‐O TIER 03 PA QLTALWIN INJ 30MG/ML BRAND TIER 03OSMOTIC DIURETICS MANNITOL INJ 10% GENERIC TIER 01MANNITOL INJ 15% GENERIC TIER 01MANNITOL INJ 20% GENERIC TIER 01MANNITOL INJ 25% GENERIC TIER 01MANNITOL INJ 5% 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= DrugExclusion206