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 StatusPHENOTHIAZINES PERPHENAZINE TAB 8MG GENERIC TIER 01PROCHLORPER INJ 5MG/ML GENERIC TIER 01PROCHLORPER SUP 25MG GENERIC TIER 01PROCHLORPER TAB 10MG GENERIC TIER 01PROCHLORPER TAB 5MG GENERIC TIER 01THIORIDAZINE TAB 100MG GENERIC TIER 01THIORIDAZINE TAB 10MG GENERIC TIER 01THIORIDAZINE TAB 25MG GENERIC TIER 01THIORIDAZINE TAB 50MG GENERIC TIER 01TRIFLUOPERAZ TAB 10MG GENERIC TIER 01TRIFLUOPERAZ TAB 1MG GENERIC TIER 01TRIFLUOPERAZ TAB 2MG GENERIC TIER 01TRIFLUOPERAZ TAB 5MG GENERIC TIER 01PHEOCHROMOCYTOMA ADREVIEW INJ BRAND TIER 99 DEHISTATROL INJ 0.275/ML BRAND TIER 03PHOSPHATE‐REMOVING AGENTS FOSRENOL CHW 1000MG BRAND TIER 02FOSRENOL CHW 500MG BRAND TIER 02FOSRENOL CHW 750MG BRAND TIER 02RENAGEL TAB 400MG BRAND TIER 03RENAGEL TAB 800MG BRAND TIER 03RENVELA PAK 0.8GM BRAND TIER 03RENVELA PAK 2.4GM BRAND TIER 03RENVELA TAB 800MG BRAND TIER 02PHOSPHODIESTERASE TYPE 4 INHIBITORS DALIRESP TAB 500MCG BRAND TIER 03 PAPHOSPHODIESTERASE TYPE 5 INHIBITORS ADCIRCA TAB 20MG BRAND TIER 03 PA SPLEVITRA TAB 10MG BRAND TIER 99 DELEVITRA TAB 2.5MG BRAND TIER 99 DELEVITRA TAB 20MG BRAND TIER 99 DELEVITRA TAB 5MG BRAND TIER 99 DEREVATIO INJ BRAND TIER 02 PA SPREVATIO TAB 20MG BRAND TIER 02 PA SPSTAXYN TAB 10MG BRAND TIER 99 DECIALIS TAB 2.5MG BRAND TIER 99 DECIALIS TAB 10MG BRAND TIER 99 DEVIAGRA TAB 25MG BRAND TIER 99 DECIALIS TAB 20MG BRAND TIER 99 DEVIAGRA TAB 50MG BRAND TIER 99 DEVIAGRA TAB 100MG BRAND TIER 99 DEPIGMENTING AGENTS 8‐MOP CAP 10MG 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= DrugExclusion227