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 StatusPIGMENTING AGENTS METHOXSALEN CRY USP/NF GENERIC TIER 99 DEOXSORALEN LOT 1% BRAND TIER 02OXSORALEN‐UL CAP 10MG BRAND TIER 02UVADEX INJ 20MCG/ML BRAND TIER 03 SPPITUITARY ACTHAR HP INJ 80UNIT BRAND TIER 02 PA SPDDAVP INJ 4MCG/ML Brand‐O TIER 03 PADDAVP SOL 0.01% Brand‐O TIER 03 PADDAVP SPR 0.01% Brand‐O TIER 03 PADDAVP TAB 0.1MG Brand‐O TIER 03 PADDAVP TAB 0.2MG Brand‐O TIER 03 PADESMOPRESSIN INJ 4MCG/ML GENERIC TIER 01DESMOPRESSIN SOL 0.01% GENERIC TIER 01DESMOPRESSIN SPR 0.01% GENERIC TIER 01DESMOPRESSIN TAB 0.1MG GENERIC TIER 01DESMOPRESSIN TAB 0.2MG GENERIC TIER 01MINIRIN SPR NASAL GENERIC TIER 01PITRESSIN INJ 20UNT/ML Brand‐O TIER 03 PASTIMATE SOL 1.5MG/ML BRAND TIER 02VASOPRESSIN INJ 10/0.5ML GENERIC TIER 01VASOPRESSIN INJ 20UNT/ML GENERIC TIER 01PITUITARY FUNCTION ACTHREL INJ 100MCG BRAND TIER 03METOPIRONE CAP 250MG BRAND TIER 03R‐GENE 10 INJ 10% BRAND TIER 03PLATELET‐AGGREGATION INHIBITORS AGGRASTAT INJ 25MG/500 BRAND TIER 03AGGRENOX CAP 25‐200MG BRAND TIER 02BRILINTA TAB 90MG BRAND TIER 02CILOSTAZOL TAB 100MG GENERIC TIER 01CILOSTAZOL TAB 50MG GENERIC TIER 01CLOPIDOGREL TAB 300MG GENERIC TIER 01CLOPIDOGREL TAB 75MG GENERIC TIER 01EFFIENT TAB 10MG BRAND TIER 02EFFIENT TAB 5MG BRAND TIER 02INTEGRILIN INJ 0.75MG/1 BRAND TIER 03INTEGRILIN INJ 2MG/ML BRAND TIER 03PLAVIX TAB 300MG Brand‐O TIER 03 PAPLAVIX TAB 75MG Brand‐O TIER 03 PAPLETAL TAB 100MG Brand‐O TIER 03 PAPLETAL TAB 50MG Brand‐O TIER 03 PAREOPRO INJ 2MG/ML 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= DrugExclusion228