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 StatusRESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHYLLINE TAB 600MG ER GENERIC TIER 01RESPIRATORY TRACT AGENTS, MISCELLANEOUS ARALAST NP INJ 1000MG BRAND TIER 02 SPARALAST NP INJ 400MG BRAND TIER 03 SPARALAST NP INJ 500MG BRAND TIER 02 SPARALAST NP INJ 800MG BRAND TIER 03 SPGLASSIA INJ BRAND TIER 03 SPKALYDECO TAB 150MG BRAND TIER 02PROLASTIN INJ 1000MG BRAND TIER 02 SPPROLASTIN INJ 500MG BRAND TIER 02 SPPROLASTIN‐C INJ 1000MG BRAND TIER 02 SPXOLAIR SOL 150MG BRAND TIER 03 PA SPZEMAIRA INJ 1000MG BRAND TIER 02 SPRIFAMYCINS XIFAXAN TAB 200MG BRAND TIER 03 PA QLXIFAXAN TAB 550MG BRAND TIER 02 PA QLROENTGENOGRAPHY BAR‐TEST TAB 650MG BRAND TIER 03CHOLOGRAFIN INJ 52% BRAND TIER 03CONRAY INJ 60% BRAND TIER 03CONRAY 30 INJ 30% BRAND TIER 03CONRAY 43 INJ 43% BRAND TIER 03CYSTO‐CONRAY INJ II 17.2% BRAND TIER 03CYSTOGRAFIN INJ 30% BRAND TIER 03CYSTOGRAFIN‐ INJ DILUTE BRAND TIER 03DIGIBAR 190 SUS BRAND TIER 99 DEENTERO VU POW 13% BRAND TIER 99 DEENTERO VU SUS 13% BRAND TIER 03ENTERO VU SUS 24% BRAND TIER 03ESOPHO‐CAT CRE 3% BRAND TIER 03E‐Z‐CAT DRY PAK BRAND TIER 03E‐Z‐DISK TAB 700MG BRAND TIER 99 DEE‐Z‐DOSE ENE BRAND TIER 03E‐Z‐HD SUS 98% BRAND TIER 03E‐Z‐PAQUE SUS 60% BRAND TIER 03E‐Z‐PAQUE SUS 96% BRAND TIER 03E‐Z‐PASTE CRE 60% BRAND TIER 99 DEFERIDEX I.V. INJ 11.2MF F BRAND TIER 03GADAVIST INJ 1MMOL/ML BRAND TIER 99 DEGASTROGRAFIN SOL Brand‐O TIER 03 PAGASTROMARK SUS 175MCG 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= DrugExclusion243