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 StatusOSMOTIC DIURETICS OSMITROL INJ 10% GENERIC TIER 01OSMITROL INJ 15% GENERIC TIER 01OSMITROL INJ 5% GENERIC TIER 01OSMITROL VFX INJ 20% GENERIC TIER 01OTHER MACROLIDES AZITHROMYCIN INJ 2.5GM GENERIC TIER 01AZITHROMYCIN INJ 500MG GENERIC TIER 01AZITHROMYCIN POW 1GM PAK GENERIC TIER 01AZITHROMYCIN SUS 100/5ML GENERIC TIER 01AZITHROMYCIN SUS 200/5ML GENERIC TIER 01AZITHROMYCIN TAB 250MG GENERIC TIER 01AZITHROMYCIN TAB 500MG GENERIC TIER 01AZITHROMYCIN TAB 600MG GENERIC TIER 01BIAXIN SUS 250/5ML Brand‐O TIER 03 PABIAXIN TAB 250MG Brand‐O TIER 03 PABIAXIN TAB 500MG Brand‐O TIER 03 PABIAXIN XL TAB 500MG Brand‐O TIER 03 PABIAXIN XL TAB PAC 500 Brand‐O TIER 03 PACLARITHROMYC SUS 125/5ML GENERIC TIER 01CLARITHROMYC SUS 250/5ML GENERIC TIER 01CLARITHROMYC TAB 250MG GENERIC TIER 01CLARITHROMYC TAB 500MG GENERIC TIER 01CLARITHROMYC TAB 500MG ER GENERIC TIER 01DIFICID TAB 200MG BRAND TIER 02 PA QLZITHROMAX INJ 500MG Brand‐O TIER 03 PAZITHROMAX POW 1GM PAK BRAND TIER 03ZITHROMAX SUS 100/5ML Brand‐O TIER 03 PAZITHROMAX SUS 200/5ML Brand‐O TIER 03 PAZITHROMAX TAB 250MG Brand‐O TIER 03 PAZITHROMAX TAB 500MG Brand‐O TIER 03 PAZITHROMAX TAB 600MG Brand‐O TIER 03 PAZITHROMAX TAB TRI‐PAK Brand‐O TIER 03 PAZITHROMAX TAB Z‐PAK Brand‐O TIER 03 PAZMAX SUS 2GM BRAND TIER 03OTHER MISCELLANEOUS THERAPEUTIC AGENTS ACUNOL TAB 600MG BRAND TIER 99 DEAMPYRA TAB 10MG BRAND TIER 03 PA QL SPAPLIGRAF MIS BRAND TIER 03ARCALYST INJ 220MG BRAND TIER 02 PA QL SPARGENTUM‐D20 INJ GENERIC TIER 99 DEKey: 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= DrugExclusion207