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 NONSTEROIDAL ANTI‐INFLAM. AGENTS VIMOVO TAB 500‐20MG BRAND TIER 02 PA QLVOLTAREN‐XR TAB 100MG Brand‐O TIER 03 PAZIPSOR CAP 25MG BRAND TIER 03 PA QLIBUPROFEN SUS 100/5ML GENERIC TIER 01OXAZOLIDINONES ZYVOX SOL 2MG/ML BRAND TIER 03 PAZYVOX SUS 100MG/5M BRAND TIER 02 PA QLZYVOX TAB 600MG BRAND TIER 02 PA QLOXYTOCICS CERVIDIL VAG MIS 10MG INS BRAND TIER 03HEMABATE INJ 250MCG BRAND TIER 03METHERGINE INJ 0.2MG/ML Brand‐O TIER 03 PAMETHERGINE TAB 0.2MG Brand‐O TIER 03 PAMETHYLERGON INJ 0.2MG/ML GENERIC TIER 01METHYLERGON TAB 0.2MG GENERIC TIER 01MIFEPREX TAB 200MG BRAND TIER 03OXYTOCIN INJ 10UNT/ML GENERIC TIER 01PITOCIN INJ 10UNT/ML Brand‐O TIER 03 PAPREPIDIL GEL 0.5MG/3G BRAND TIER 03PROSTIN E2 SUP 20MG BRAND TIER 03PANCREATIC FUNCTION CHIRHOSTIM SOL 16MCG BRAND TIER 99 DESECREFLO INJ 16MCG BRAND TIER 03PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) ARICEPT TAB 10MG Brand‐O TIER 03 PAARICEPT TAB 23MG BRAND TIER 02ARICEPT TAB 5MG Brand‐O TIER 03 PAARICEPT ODT TAB 10MG Brand‐O TIER 03 PAARICEPT ODT TAB 5MG Brand‐O TIER 03 PABETHANECHOL TAB 10MG GENERIC TIER 01BETHANECHOL TAB 25MG GENERIC TIER 01BETHANECHOL TAB 50MG GENERIC TIER 01BETHANECHOL TAB 5MG GENERIC TIER 01DONEPEZIL TAB 10MG GENERIC TIER 01DONEPEZIL TAB 10MG ODT GENERIC TIER 01DONEPEZIL TAB 5MG GENERIC TIER 01DONEPEZIL TAB 5MG ODT GENERIC TIER 01ENLON‐PLUS INJ 10‐0.14 BRAND TIER 03EVOXAC CAP 30MG Brand‐O TIER 02 PAEXELON CAP 1.5MG Brand‐O TIER 03 PAEXELON CAP 3MG Brand‐O TIER 03 PAEXELON CAP 4.5MG 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= DrugExclusion216