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 StatusPROTECTIVE AGENTS TOTECT INJ 500MG BRAND TIER 99 DEZINECARD INJ 250MG Brand‐O TIER 03 PA SPZINECARD INJ 500MG Brand‐O TIER 99 PA DEPROTON‐PUMP INHIBITORS ACIPHEX TAB 20MG BRAND TIER 03 PA QLDEXILANT CAP 30MG DR BRAND TIER 03 PA QLDEXILANT CAP 60MG DR BRAND TIER 03 PA QLFIRST‐OMEPRA SUS 2MG/ML BRAND TIER 03 PALANSOPRAZOLE CAP 15MG DR GENERIC TIER 01 PA QLLANSOPRAZOLE CAP 30MG DR GENERIC TIER 01 PA QLLANSOPRAZOLE SUS 3MG/ML BRAND TIER 03 PALANSOPRAZOLE TAB 15MG ODT GENERIC TIER 01 PA QLLANSOPRAZOLE TAB 30MG ODT GENERIC TIER 01 PA QLNEXIUM CAP 20MG BRAND TIER 02 PA QLNEXIUM CAP 40MG BRAND TIER 02 PA QLNEXIUM GRA 10MG DR BRAND TIER 02 PA QLNEXIUM GRA 2.5MG DR BRAND TIER 02 PANEXIUM GRA 20MG DR BRAND TIER 02 PA QLNEXIUM GRA 40MG DR BRAND TIER 02 PA QLNEXIUM GRA 5MG DR BRAND TIER 02 PANEXIUM I.V. INJ 20MG BRAND TIER 03NEXIUM I.V. INJ 40MG BRAND TIER 03OMECLAMOX‐ MIS PAK BRAND TIER 03OMEPRA/BICAR CAP 20‐1100 GENERIC TIER 01 PA QLOMEPRA/BICAR CAP 40‐1100 GENERIC TIER 01 PA QLOMEPRAZOLE CAP 10MG GENERIC TIER 01 PA QLOMEPRAZOLE CAP 20MG GENERIC TIER 01 PA QLOMEPRAZOLE CAP 40MG GENERIC TIER 01 PA QLPANTOPRAZOLE TAB 20MG GENERIC TIER 01 PA QLPANTOPRAZOLE TAB 40MG GENERIC TIER 01 PA QLPREVACID CAP 15MG DR Brand‐O TIER 03 PA QLPREVACID CAP 30MG DR Brand‐O TIER 03 PA QLPREVACID TAB 15MG STB BRAND TIER 03 PA QLPREVACID TAB 30MG STB BRAND TIER 03 PA QLPREVPAC MIS BRAND TIER 03 PAPRILOSEC CAP 10MG Brand‐O TIER 03 PA QLPRILOSEC CAP 20MG Brand‐O TIER 03 PA QLPRILOSEC CAP 40MG Brand‐O TIER 03 PA QLPRILOSEC POW 10MG BRAND TIER 03 PA QLPRILOSEC POW 2.5MG BRAND TIER 03 PA QLKey: 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= DrugExclusion234
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPROTON‐PUMP INHIBITORS PROTONIX INJ 40MG BRAND TIER 03 PAPROTONIX PAK BRAND TIER 03 PA QLPROTONIX TAB 20MG Brand‐O TIER 03 PA QLPROTONIX TAB 40MG Brand‐O TIER 03 PA QLZEGERID CAP 20‐1100 Brand‐O TIER 03 PA QLZEGERID CAP 40‐1100 Brand‐O TIER 03 PA QLZEGERID POW 20‐1680 BRAND TIER 03 PA QLZEGERID POW 40‐1680 BRAND TIER 03 PA QLPULMONARY SURFACTANTS CUROSURF SUS 80MG/ML BRAND TIER 03INFASURF SUS 35MG/ML BRAND TIER 03SURVANTA INH BRAND TIER 03PYRIMIDINES ANCOBON CAP 250MG Brand‐O TIER 03 PAANCOBON CAP 500MG Brand‐O TIER 03 PAFLUCYTOSINE CAP 250MG GENERIC TIER 01FLUCYTOSINE CAP 500MG GENERIC TIER 01QUINOLONES AVELOX INJ BRAND TIER 02AVELOX TAB 400MG BRAND TIER 02AVELOX ABC TAB 400MG BRAND TIER 02CIPRO TAB 250MG Brand‐O TIER 03 PACIPRO TAB 500MG Brand‐O TIER 03 PACIPRO (10%) SUS 500MG/5 BRAND TIER 02CIPRO (5%) SUS 250MG/5 BRAND TIER 02CIPROFLOXACN INJ 200MG GENERIC TIER 99 DECIPROFLOXACN INJ 400MG GENERIC TIER 99 DECIPROFLOXACN TAB 1000MG GENERIC TIER 01CIPROFLOXACN TAB 100MG GENERIC TIER 01CIPROFLOXACN TAB 250MG GENERIC TIER 01CIPROFLOXACN TAB 500MG GENERIC TIER 01CIPROFLOXACN TAB 500MG ER GENERIC TIER 01CIPROFLOXACN TAB 750MG GENERIC TIER 01FACTIVE TAB 320MG BRAND TIER 03LEVAQUIN INJ 25MG/ML Brand‐O TIER 03 PALEVAQUIN SOL 25MG/ML Brand‐O TIER 03 PALEVAQUIN TAB 250MG Brand‐O TIER 03 PALEVAQUIN TAB 500MG Brand‐O TIER 03 PALEVAQUIN TAB 750MG Brand‐O TIER 03 PALEVAQUIN/D5W INJ 250/50ML Brand‐O TIER 03 PALEVAQUIN/D5W INJ 500/100M Brand‐O TIER 03 PALEVAQUIN/D5W INJ 750/150 Brand‐O TIER 03 PAKey: 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= DrugExclusion235
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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