BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS SYNVISC ONE INJ 8MG/ML BRAND TIER 02 PA QL SPSYZYGIUM DRO COMPOSIT BRAND TIER 99 DETEARS AGAIN CAP HYDRATE Brand‐O TIER 03 PATHALAMUS SUB COMPOSIT BRAND TIER 99 DETHIOLA TAB 100MG BRAND TIER 03THYREOIDEA LIQ COMPOSIT BRAND TIER 99 DETHYREOIDEA SUB COMPOSIT BRAND TIER 99 DETRANZGEL GEL BRAND TIER 99 DETRAUMANIL GEL BRAND TIER 99 DETRAUMEEL INJ BRAND TIER 99 DETRI‐CHLOR LIQ 80% BRAND TIER 03UBICHINON INJ COMPOSIT BRAND TIER 99 DEURI‐CLEANSE TAB RX BRAND TIER 99 DEURI‐CONTROL TAB RX BRAND TIER 99 DEVALERIAN EXT ROOT GENERIC TIER 01VAYACOG CAP BRAND TIER 99 DEVAYARIN CAP BRAND TIER 99 DEVAYAROL CAP BRAND TIER 03VENOMIL KIT HONEYBEE BRAND TIER 03VENOMIL KIT WASP BRAND TIER 03VENOMIL KIT WHT HORN BRAND TIER 03VENOMIL KIT YEL HORN BRAND TIER 03VENOMIL KIT YEL JACK BRAND TIER 03VENOMIL MIX INJ VESPID BRAND TIER 03VERTIGOHEEL DRO BRAND TIER 99 DEVERTIGOHEEL LIQ BRAND TIER 99 DEVERTIGOHEEL SUB BRAND TIER 99 DEVIASPAN SOL BRAND TIER 03VP‐GSTN CAP GENERIC TIER 01VP‐PRECIP CAP GENERIC TIER 01WASP VENOM INJ 1000MCG GENERIC TIER 01WASP VENOM INJ 1300MCG GENERIC TIER 01WASP VENOM INJ 550MCG GENERIC TIER 01WASP VENOM KIT 100MCG GENERIC TIER 01WHITE HORNET KIT 100MCG GENERIC TIER 01WHITE HORNET SOL 1000MCG GENERIC TIER 01XEOMIN INJ 100UNIT BRAND TIER 03 PA SPXEOMIN INJ 50 UNIT BRAND TIER 03 PA SPXIGRIS INJ 20MG 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= DrugExclusion212
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS XIGRIS INJ 5MG BRAND TIER 03YELLOW HORN INJ 550MCG GENERIC TIER 01YELLOW HORNT KIT 100MCG GENERIC TIER 01YELLOW HORNT SOL 1000MCG GENERIC TIER 01YELLOW JACK INJ 1300MCG GENERIC TIER 01YELLOW JACK INJ 550MCG GENERIC TIER 01YELLOW JACKT KIT 100MCG GENERIC TIER 01YELLOW JACKT SOL 1000MCG GENERIC TIER 01ZAVESCA CAP 100MG BRAND TIER 03 SPZEEL INJ BRAND TIER 99 DETRICHLOROACE CRY ACID GENERIC TIER 99 DEOTHER NONSTEROIDAL ANTI‐INFLAM. AGENTS ANAPROX TAB 275MG Brand‐O TIER 03 PAANAPROX DS TAB 550MG Brand‐O TIER 03 PAARTHROTEC 50 TAB BRAND TIER 03ARTHROTEC 75 TAB BRAND TIER 03CALDOLOR INJ 400/4ML BRAND TIER 99 DECALDOLOR INJ 800/8ML BRAND TIER 99 DECAMBIA POW 50MG BRAND TIER 03 PACATAFLAM TAB 50MG Brand‐O TIER 03 PACLINORIL TAB 200MG Brand‐O TIER 03 PADAYPRO TAB 600MG Brand‐O TIER 03 PADICLOFEN POT TAB 50MG GENERIC TIER 01DICLOFENAC TAB 100MG ER GENERIC TIER 01DICLOFENAC TAB 100MG XR GENERIC TIER 01DICLOFENAC TAB 25MG DR GENERIC TIER 01DICLOFENAC TAB 50MG DR GENERIC TIER 01DICLOFENAC TAB 75MG DR GENERIC TIER 01DIFLUNISAL TAB 500MG GENERIC TIER 01DUEXIS TAB 800‐26.6 BRAND TIER 03EC‐NAPROSYN TAB 375MG Brand‐O TIER 03 PAEC‐NAPROSYN TAB 500MG Brand‐O TIER 03 PAETODOLAC CAP 200MG GENERIC TIER 01ETODOLAC CAP 300MG GENERIC TIER 01ETODOLAC TAB 400MG GENERIC TIER 01ETODOLAC TAB 500MG GENERIC TIER 01ETODOLAC ER TAB 400MG GENERIC TIER 01ETODOLAC ER TAB 500MG GENERIC TIER 01ETODOLAC ER TAB 600MG GENERIC TIER 01FELDENE CAP 10MG Brand‐O TIER 03 PAKey: 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= DrugExclusion213
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BMC HealthNet Plan Drug List - Comm
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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