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 StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS LIMBREL500 CAP 500‐50MG BRAND TIER 99 DELIMBREL525 CAP 525‐50MG BRAND TIER 03L‐METHYLFOLA TAB 15MG GENERIC TIER 99 DEL‐METHYLFOLA TAB 7.5MG GENERIC TIER 01LYMPHOMYOSOT INJ BRAND TIER 99 DELYMPHOMYSOT INJ BRAND TIER 99 DEMELILOTUS DRO HOMACCOR BRAND TIER 99 DEMELILOTUS LIQ HOMACCOR BRAND TIER 99 DEMETASTRON INJ BRAND TIER 03 SPMIXED VESPID INJ 1650MCG GENERIC TIER 01MIXED VESPID INJ 3900MCG GENERIC TIER 01MIXED VESPID KIT 3000MCG GENERIC TIER 01MIXED VESPID KIT 300MCG GENERIC TIER 01MOMORDICA DRO COMPOSIT BRAND TIER 99 DEMOMORDICA LIQ COMPOSIT BRAND TIER 99 DEMUCOSA INJ COMPOSIT BRAND TIER 99 DEMYOBLOC INJ 10000/2 BRAND TIER 03 PA SPMYOBLOC INJ 2500/0.5 BRAND TIER 03 PA SPMYOBLOC INJ 5000/ML BRAND TIER 03 PA SPNEURALGO INJ RHEUM BRAND TIER 99 DENEXAVIR INJ BRAND TIER 03OCTREOSCAN KIT BRAND TIER 03OCTREOTIDE INJ 1000MCG GENERIC TIER 01OCTREOTIDE INJ 100MCG GENERIC TIER 01OCTREOTIDE INJ 200MCG GENERIC TIER 01OCTREOTIDE INJ 500MCG GENERIC TIER 01OCTREOTIDE INJ 50MCG/ML GENERIC TIER 01OLEIC ACID LIQ GENERIC TIER 99 DEORFADIN CAP 10MG BRAND TIER 02 SPORFADIN CAP 2MG BRAND TIER 02 SPORFADIN CAP 5MG BRAND TIER 02 SPORTHOVISC INJ 15MG/ML BRAND TIER 03 PA QL SPPLACENTA INJ COMPOSIT BRAND TIER 99 DEPNEUMODORON LIQ BRAND TIER 99 DEPOLYPEG SUP MIS BASE GENERIC TIER 99 DEPROSTASCINT KIT BRAND TIER 03PRYFLEX TAB BRAND TIER 03PSORINOHEEL DRO BRAND TIER 99 DEPSORINOHEEL LIQ BRAND 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= DrugExclusion210