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 StatusPARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) SALAGEN TAB 7.5MG Brand‐O TIER 03 PAURECHOLINE TAB 10MG Brand‐O TIER 03 PAURECHOLINE TAB 25MG Brand‐O TIER 03 PAURECHOLINE TAB 50MG Brand‐O TIER 03 PAURECHOLINE TAB 5MG Brand‐O TIER 03 PACEVIMELINE CAP 30MG GENERIC TIER 01PARATHYROID CALCITONIN SPR 200/ACT GENERIC TIER 01FORTEO SOL 600/2.4 BRAND TIER 02 PA SPFORTICAL SPR 200/ACT GENERIC TIER 01MIACALCIN INJ 200/ML BRAND TIER 03MIACALCIN SPR 200/ACT Brand‐O TIER 03 PAPENICILLINASE‐RESISTANT PENICILLINS BACTOCILL INJ DEX 1GM BRAND TIER 03BACTOCILL INJ DEX 2GM BRAND TIER 03DICLOXACILL CAP 250MG GENERIC TIER 01DICLOXACILL CAP 500MG GENERIC TIER 01NAFCILLIN INJ 10GM GENERIC TIER 01 SPNAFCILLIN INJ 1GM GENERIC TIER 01 SPNAFCILLIN INJ 2GM GENERIC TIER 01 SPNALLPEN/DEX INJ 1GM/50ML BRAND TIER 03NALLPEN/DEX INJ 2GM/100 BRAND TIER 03OXACILLIN INJ 10GM GENERIC TIER 01OXACILLIN INJ 1GM GENERIC TIER 01OXACILLIN INJ 2GM GENERIC TIER 01PERIPHERAL ADRENERGIC INHIBITORS RESERPINE TAB 0.1MG GENERIC TIER 01RESERPINE TAB 0.25MG GENERIC TIER 01PHARMACEUTICAL AIDS ALBA‐DERM CRE BRAND TIER 03ALMOND OIL LIQ BITTER GENERIC TIER 99 DEANHYDROUS GEL BASE GENERIC TIER 99 DEANHYDROUS OIN BASE BRAND TIER 03ANHYDROUS OIN BASE GENERIC TIER 01ANISE EXTRAC LIQ FLAVOR GENERIC TIER 99 DEANISE FLAVOR OIL GENERIC TIER 99 DEAPPLE FLAVOR LIQ GENERIC TIER 99 DEAPRICOT LIQ FLAVOR GENERIC TIER 99 DEAZ CREAM CRE BRAND TIER 03BACON FLAVOR LIQ GENERIC TIER 99 DEBACTER WATER INJ BENZ ALC GENERIC TIER 01BACTER WATER INJ PARABENS GENERIC TIER 01BANANA LIQ FLAVOR 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= DrugExclusion218
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS BANANA CREME LIQ FLAVOR GENERIC TIER 99 DEBASE W301 CRE GENERIC TIER 01BASE X MIS GENERIC TIER 99 DEBEES WAX MIS WHITE GENERIC TIER 99 DEBENZALDEHYDE ELX GENERIC TIER 99 DEBIOPEPTIDE CRE BASE BRAND TIER 03BITTER STOP LIQ FLAVOR GENERIC TIER 99 DEBLACK WALNUT LIQ FLAVOR GENERIC TIER 99 DEBLACKBERRY LIQ FLAVOR GENERIC TIER 99 DEBLUEBERRY LIQ FLAVOR GENERIC TIER 99 DEBUBBLE GUM LIQ CONCENTR GENERIC TIER 99 DEBUBBLE GUM LIQ FLAVOR GENERIC TIER 99 DEBUTTER LIQ FLAVOR GENERIC TIER 99 DEBUTTER RUM LIQ FLAVOR GENERIC TIER 99 DEBUTTERSCOTCH LIQ FLAVOR GENERIC TIER 99 DECAP POSILOK CAP #0 GENERIC TIER 01CAP POSILOK CAP #00 GENERIC TIER 01CAP POSILOK CAP #2 GENERIC TIER 01CAP POSILOK CAP #3 GENERIC TIER 01CAPSULE #1 CAP DRCAPS GENERIC TIER 01CAPSULE CONI CAP ‐SN #000 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #1 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #2 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #3 GENERIC TIER 01CAPSULE CONI CAP ‐SNAP #4 GENERIC TIER 01CAPSULE LOCK CAP #0 CLEAR GENERIC TIER 01CAPSULE LOCK CAP #1 CLEAR GENERIC TIER 01CAPSULE LOCK CAP #3 CLEAR GENERIC TIER 01CARBOGEL GEL 940 GENERIC TIER 01CARBOHOL GEL 940 BRAND TIER 03CARBOMER GEL AQUEOUS GENERIC TIER 01CARBOMER GEL HYDROALC GENERIC TIER 01CAVIAR FLAVO LIQ NATURAL GENERIC TIER 99 DECETYL ALCOHO MIS GENERIC TIER 99 DECHCK FLAVOR LIQ OIL SOLU GENERIC TIER 99 DECHCK FLAVOR LIQ WTR MISC GENERIC TIER 99 DECHEESECAKE LIQ FLAVOR GENERIC TIER 99 DECHEMSIL K‐12 PST BRAND TIER 99 DECHEMSIL K‐51 GEL 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= DrugExclusion219
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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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