BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

More documents

Recommendations

Info

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSCABICIDES AND PEDICULICIDES SULF LIME SOL USP GENERIC TIER 01ULESFIA LOT 5% BRAND TIER 02ELIMITE CRE 5% Brand‐O TIER 03 PASCLEROSING AGENTS ASCLERA INJ 0.5% BRAND TIER 03ASCLERA INJ 1% BRAND TIER 03ETHAMOLIN INJ 5% BRAND TIER 03MORRHUAT SOD INJ 5% GENERIC TIER 01SCLEROMATE INJ 5% GENERIC TIER 01SCLEROSOL AER INTRAPLE BRAND TIER 03SOTRADECOL INJ 1% BRAND TIER 03SOTRADECOL INJ 3% BRAND TIER 03STERIL TALC SUS 5GM BRAND TIER 03SECOND GENERATION ANTIHISTAMINES CETIRIZINE SYP 5MG/5ML GENERIC TIER 01 PACLARINEX SYP 0.5MG/ML BRAND TIER 02 PACLARINEX TAB 5MG Brand‐O TIER 03 PACLARINEX RDT TAB 2.5MG BRAND TIER 02 PACLARINEX RDT TAB 5MG BRAND TIER 02 PADESLORATADIN TAB 5MG GENERIC TIER 01 PAFEXOFENADINE TAB 180MG GENERIC TIER 01 PAFEXOFENADINE TAB 30MG GENERIC TIER 01 PAFEXOFENADINE TAB 60MG GENERIC TIER 01 PALEVOCETIRIZI SOL 2.5/5ML GENERIC TIER 01 PALEVOCETIRIZI TAB DHCL 5MG GENERIC TIER 01 PASEMPREX‐D CAP 8‐60MG BRAND TIER 99 DEXYZAL SOL Brand‐O TIER 03 PAXYZAL TAB 5MG Brand‐O TIER 03 PAFEXOFEN/PSE TAB 60‐120MG GENERIC TIER 99 DECETIRIZINE SYP 1MG/ML GENERIC TIER 01 PASECOND GENERATION CEPHALOSPORINS CEFACLOR CAP 250MG GENERIC TIER 01CEFACLOR CAP 500MG GENERIC TIER 01CEFACLOR ER TAB 500MG GENERIC TIER 01CEFPROZIL SUS 125/5ML GENERIC TIER 01CEFPROZIL SUS 250/5ML GENERIC TIER 01CEFPROZIL TAB 250MG GENERIC TIER 01CEFPROZIL TAB 500MG GENERIC TIER 01CEFTIN SUS 125/5ML Brand‐O TIER 02 PACEFTIN SUS 250/5ML BRAND TIER 02CEFTIN TAB 250MG Brand‐O TIER 03 PACEFTIN TAB 500MG 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= DrugExclusion246
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSECOND GENERATION CEPHALOSPORINS CEFUROX/DEXT INJ 1.5GM GENERIC TIER 01CEFUROX/DEXT INJ 750MG GENERIC TIER 01CEFUROXIME INJ 1.5GM GENERIC TIER 01CEFUROXIME INJ 225GM GENERIC TIER 01CEFUROXIME INJ 7.5GM GENERIC TIER 01CEFUROXIME INJ 750MG GENERIC TIER 01CEFUROXIME INJ 75GM GENERIC TIER 01CEFUROXIME SUS 125/5ML GENERIC TIER 01CEFUROXIME TAB 250MG GENERIC TIER 01CEFUROXIME TAB 500MG GENERIC TIER 01ZINACEF INJ 1.5GM Brand‐O TIER 03 PAZINACEF INJ 7.5GM GENERIC TIER 01ZINACEF INJ 750MG BRAND TIER 03ZINACEF/D5W INJ 750MG PB BRAND TIER 03ZINACEF/H20 INJ 1.5GM PB BRAND TIER 03SEL. SEROTONIN & NOREPI REUPTAKE INHIBTR CYMBALTA CAP 20MG BRAND TIER 02 PA QLCYMBALTA CAP 30MG BRAND TIER 02 PA QLCYMBALTA CAP 60MG BRAND TIER 02 PA QLEFFEXOR XR CAP 150MG Brand‐O TIER 03 PA QLEFFEXOR XR CAP 37.5MG Brand‐O TIER 03 PA QLEFFEXOR XR CAP 75MG Brand‐O TIER 03 PA QLPRISTIQ TAB 100MG BRAND TIER 02 PA QLPRISTIQ TAB 50MG BRAND TIER 02 PA QLVENLAFAXINE CAP 150MG ER GENERIC TIER 01 QLVENLAFAXINE CAP 37.5MG GENERIC TIER 01 QLVENLAFAXINE CAP 75MG ER GENERIC TIER 01 QLVENLAFAXINE TAB 100MG GENERIC TIER 01 QLVENLAFAXINE TAB 150MG ER GENERIC TIER 01 QLVENLAFAXINE TAB 225MG ER GENERIC TIER 01 QLVENLAFAXINE TAB 25MG GENERIC TIER 01 QLVENLAFAXINE TAB 37.5 ER GENERIC TIER 01 QLVENLAFAXINE TAB 37.5MG GENERIC TIER 01 QLVENLAFAXINE TAB 50MG GENERIC TIER 01 QLVENLAFAXINE TAB 75MG GENERIC TIER 01 QLVENLAFAXINE TAB 75MG ER GENERIC TIER 01 QLSELECTIVE ALPHA‐1‐ADRENERGIC BLOCK.AGENT ALFUZOSIN TAB 10MG GENERIC TIER 01 PA QLFLOMAX CAP 0.4MG 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= DrugExclusion247
Page 1 and 2:
BMC HealthNet Plan Drug List - Comm
Page 3 and 4:
AHFS Therapeutic Class Description
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197: AHFS Therapeutic Class Description
Page 280: AHFS Therapeutic Class Description
show all

BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?