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 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
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPLATELET‐AGGREGATION INHIBITORS TICLOPIDINE TAB 250MG GENERIC TIER 01PLATELET‐REDUCING AGENTS AGRYLIN CAP 0.5MG Brand‐O TIER 03 PAANAGRELIDE CAP 0.5MG GENERIC TIER 01ANAGRELIDE CAP 1MG GENERIC TIER 01POLYENES ABELCET INJ 5MG/ML BRAND TIER 03AMBISOME INJ 50MG BRAND TIER 03AMPHOTEC INJ 100MG BRAND TIER 03AMPHOTEC INJ 50MG BRAND TIER 03AMPHOTERICIN INJ 50MG GENERIC TIER 01BIO‐STATIN CAP 1000000 BRAND TIER 03BIO‐STATIN CAP 500000 BRAND TIER 03BXN MOUTHWSH SUS BRAND TIER 03FIRST DUKES SUS MOUTHWSH BRAND TIER 03FIRST‐MARYS SUS MOUTHWSH BRAND TIER 03NYSTATIN POW GENERIC TIER 99 DENYSTATIN POW 10BU GENERIC TIER 99 DENYSTATIN POW 150MU GENERIC TIER 99 DENYSTATIN POW 1BU GENERIC TIER 99 DENYSTATIN POW 2BU GENERIC TIER 99 DENYSTATIN POW 500MU GENERIC TIER 99 DENYSTATIN POW 50MU GENERIC TIER 99 DENYSTATIN POW 5BU GENERIC TIER 99 DENYSTATIN POW DOMESTIC GENERIC TIER 99 DENYSTATIN SUS 100000 GENERIC TIER 01NYSTATIN TAB 500000 GENERIC TIER 01POLYENES (SKIN & MUCOUS MEMBRANE) NYSTATIN CRE 100000 GENERIC TIER 01NYSTATIN OIN 100000 GENERIC TIER 01NYSTATIN VAG TAB 100000 GENERIC TIER 01PEDIADERM AF KIT COMPLETE BRAND TIER 03POLYMYXINS COLISTIMETH INJ 150MG GENERIC TIER 01COLY‐MYCIN M INJ 150MG Brand‐O TIER 03 PAPOLYMYXIN B INJ 500000 GENERIC TIER 01POTASSIUM‐REMOVING AGENTS KIONEX SUS 15GM/60 GENERIC TIER 01SOD POLY SUL SUS 15GM/60 GENERIC TIER 01SPS SUS 15GM/60 GENERIC TIER 01POTASSIUM‐SPARING DIURETICS AMILOR/HCTZ TAB 5‐50 GENERIC TIER 01AMILORIDE TAB 5MG GENERIC TIER 01DYAZIDE CAP 37.5‐25 Brand‐O TIER 03 PADYRENIUM CAP 100MG 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= DrugExclusion229
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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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