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 PSORIZIDE TAB FORTE GENERIC TIER 99 DEPSORIZIDE TAB ULTRA BRAND TIER 99 DEPULSATILLA INJ COMPOSIT BRAND TIER 99 DEQUINZYME TAB 90MG BRAND TIER 99 DERASPBERRY SYP GENERIC TIER 01RAUWOLFIA LIQ COMPOSIT GENERIC TIER 99 DERAUWOLFIA SUB COMPOSIT GENERIC TIER 99 DEREJUVESOL SOL BRAND TIER 03RELAMINE TAB BRAND TIER 03RENEEL SUB BRAND TIER 99 DERHEUMADORON LIQ 102A BRAND TIER 99 DERIMSO‐50 SOL 50% BRAND TIER 03SANDOSTATIN INJ 1000MCG Brand‐O TIER 03 PASANDOSTATIN INJ 100MCG Brand‐O TIER 03 PASANDOSTATIN INJ 200MCG Brand‐O TIER 03 PASANDOSTATIN INJ 500MCG Brand‐O TIER 03 PASANDOSTATIN INJ 50MCG/ML Brand‐O TIER 03 PASANDOSTATIN KIT LAR 10MG BRAND TIER 02SANDOSTATIN KIT LAR 20MG BRAND TIER 02SANDOSTATIN KIT LAR 30MG BRAND TIER 02SARAPIN INJ BRAND TIER 03SENSIPAR TAB 30MG BRAND TIER 02 SPSENSIPAR TAB 60MG BRAND TIER 02 SPSENSIPAR TAB 90MG BRAND TIER 02 SPSOLESTA INJ 50‐15ML BRAND TIER 03SOMATULINE INJ 120/.5ML BRAND TIER 02 SPSOMATULINE INJ 60/0.2ML BRAND TIER 02 SPSOMATULINE INJ 90/0.3ML BRAND TIER 02 SPSPASCUPREEL INJ BRAND TIER 99 DESPEED GEL GEL TRAUMA BRAND TIER 99 DESPEED GEL RX GEL BRAND TIER 99 DESPG SUPPOSI‐ MIS BASE BRAND TIER 99 DESTAPHAGE LYS INJ GENERIC TIER 01STERYMINE GEL BRAND TIER 99 DESTRUMEEL DRO FORTE BRAND TIER 99 DESTRUMEEL SUB BRAND TIER 99 DESUPARTZ INJ 25/2.5ML BRAND TIER 03 PA QL SPSUPPOSIBLEND MIS BRAND TIER 99 DESYNVISC INJ 8MG/ML BRAND TIER 02 PA QL SPKey: 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= DrugExclusion211