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 StatusPROPYLAMINE DERIVATIVES RU‐HIST TAB FORTE GENERIC TIER 99 DERU‐TUSS TAB GENERIC TIER 99 DERYNATAN PEDI CHW 4.5‐5MG BRAND TIER 99 DERYNEZE LIQ BRAND TIER 03SUDAHIST TAB 12‐120MG GENERIC TIER 99 DEVAZOL LIQ 2MG/5ML BRAND TIER 03VAZOTAB CHW GENERIC TIER 99 DEV‐HIST SUS 6‐10MG/5 GENERIC TIER 99 DEZOTEX PE TAB BRAND TIER 99 DEZOTEX‐PE TAB 6‐30MG GENERIC TIER 99 DERYNATAN TAB 9‐25MG Brand‐O TIER 99 PA DEJ‐TAN D CHW 2.2‐1.58 Brand‐O TIER 99 PA DEPEDIATEX TD LIQ Brand‐O TIER 99 PA DERYNATAN PED SUS Brand‐O TIER 99 PA DEVAZOBID SUS 6‐10MG/5 Brand‐O TIER 99 PA DEDALLERGY JR CAP 4‐20MG Brand‐O TIER 99 PA DELODRANE 12D TAB 6‐45MG Brand‐O TIER 99 PA DESTAHIST TAB Brand‐O TIER 99 PA DEJ‐TAN D SR TAB 6‐30MG Brand‐O TIER 99 PA DEPROSTAGLANDIN ANALOGS LATANOPROST SOL 0.005% GENERIC TIER 01LUMIGAN SOL 0.01% BRAND TIER 02LUMIGAN SOL 0.03% BRAND TIER 02TRAVATAN Z DRO 0.004% BRAND TIER 02XALATAN SOL 0.005% Brand‐O TIER 03 PAZIOPTAN DRO 0.0015% BRAND TIER 03PROSTAGLANDINS CYTOTEC TAB 100MCG Brand‐O TIER 03 PACYTOTEC TAB 200MCG Brand‐O TIER 03 PAMISOPROSTOL TAB 100MCG GENERIC TIER 01MISOPROSTOL TAB 200MCG GENERIC TIER 01PROTECTANTS CARAFATE SUS 1GM/10ML BRAND TIER 02CARAFATE TAB 1GM Brand‐O TIER 03 PASUCRALFATE TAB 1GM GENERIC TIER 01PROTECTIVE AGENTS AMIFOSTINE INJ 500MG GENERIC TIER 01 SPDEXRAZOXANE INJ 250MG GENERIC TIER 01 SPDEXRAZOXANE INJ 500MG GENERIC TIER 99 DEETHYOL INJ 500MG Brand‐O TIER 03 PA SPMESNA INJ 1GM GENERIC TIER 01 SPMESNEX INJ 1GM Brand‐O TIER 03 PA SPMESNEX TAB 400MG BRAND TIER 02Key: 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= DrugExclusion233