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 StatusSELECTIVE‐SEROTONIN REUPTAKE INHIBITORS SARAFEM TAB 20MG BRAND TIER 03 PA QLSENTRAFLOX PAK AM‐10 BRAND TIER 03SENTRALOPRAM PAK AM‐10 BRAND TIER 03SENTROXATINE PAK BRAND TIER 03SERTRALINE CON 20MG/ML GENERIC TIER 01SERTRALINE TAB 100MG GENERIC TIER 01SERTRALINE TAB 100MG QLSERTRALINE TAB 25MG GENERIC TIER 01SERTRALINE TAB 25MG QLSERTRALINE TAB 50MG GENERIC TIER 01SERTRALINE TAB 50MG QLSYMBYAX CAP 12‐25MG Brand‐O TIER 03 PA QLSYMBYAX CAP 12‐50MG Brand‐O TIER 03 PA QLSYMBYAX CAP 3‐25MG BRAND TIER 03 QLSYMBYAX CAP 6‐25MG Brand‐O TIER 03 PA QLSYMBYAX CAP 6‐50MG Brand‐O TIER 03 PA QLZOLOFT CON 20MG/ML Brand‐O TIER 03 PAZOLOFT TAB 100MG Brand‐O TIER 03 PA QLZOLOFT TAB 25MG Brand‐O TIER 03 PA QLZOLOFT TAB 50MG Brand‐O TIER 03 PA QLPAXIL TAB 20MG Brand‐O TIER 03 PA QLSEROTONIN MODULATORS NEFAZODONE TAB 100MG GENERIC TIER 01NEFAZODONE TAB 150MG GENERIC TIER 01NEFAZODONE TAB 200MG GENERIC TIER 01NEFAZODONE TAB 250MG GENERIC TIER 01NEFAZODONE TAB 50MG GENERIC TIER 01OLEPTRO TAB 24HR150 BRAND TIER 03 PA QLOLEPTRO TAB 24HR300 BRAND TIER 03 PA QLTRAZAMINE PAK BRAND TIER 03TRAZODONE TAB 100MG GENERIC TIER 01TRAZODONE TAB 150MG GENERIC TIER 01TRAZODONE TAB 300MG GENERIC TIER 01TRAZODONE TAB 50MG GENERIC TIER 01VIIBRYD KIT BRAND TIER 02 PAVIIBRYD TAB 10MG BRAND TIER 02 PA QLVIIBRYD TAB 20MG BRAND TIER 02 PA QLVIIBRYD TAB 40MG BRAND TIER 02 PA QLSERUMS ANASCORP INJ BRAND TIER 03ANTIVENIN KIT LAT MACT GENERIC TIER 01Key: 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= DrugExclusion252
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSERUMS ANTIVENIN MI KIT GENERIC TIER 01CARIMUNE NF INJ 12GM GENERIC TIER 01 PA SPCARIMUNE NF INJ 3GM GENERIC TIER 01 PA SPCARIMUNE NF INJ 6GM GENERIC TIER 01 PA SPCROFAB INJ BRAND TIER 03CYTOGAM INJ BRAND TIER 03 SPDIGIFAB INJ 40MG BRAND TIER 03FLEBOGAMMA INJ 10% BRAND TIER 03 PA SPFLEBOGAMMA INJ 5% GENERIC TIER 01 PA SPFLEBOGAMMA INJ DIF 5% BRAND TIER 03 PA SPGAMASTAN S/D INJ GENERIC TIER 01 PA SPGAMMAGARD INJ 10GM/100 GENERIC TIER 01 SPGAMMAGARD INJ 1GM/10ML GENERIC TIER 01 SPGAMMAGARD INJ 2.5GM/25 GENERIC TIER 01 SPGAMMAGARD INJ 20GM/200 GENERIC TIER 01 SPGAMMAGARD INJ 30GM/300 BRAND TIER 02 SPGAMMAGARD INJ 5GM/50ML GENERIC TIER 01 SPGAMMAGARD SD INJ 10GM HU BRAND TIER 03 PA SPGAMMAGARD SD INJ 2.5GM HU GENERIC TIER 01 PA SPGAMMAGARD SD INJ 5GM HU BRAND TIER 03 PA SPGAMMAKED INJ 10GM/100 BRAND TIER 03 SPGAMMAKED INJ 1GM/10ML BRAND TIER 03 SPGAMMAKED INJ 2.5GM/25 BRAND TIER 03 SPGAMMAKED INJ 20GM/200 BRAND TIER 03 SPGAMMAKED INJ 5GM/50ML BRAND TIER 03 SPGAMMAPLEX INJ 10GM BRAND TIER 03 PA SPGAMMAPLEX INJ 2.5GM BRAND TIER 03 PA SPGAMMAPLEX INJ 5GM BRAND TIER 03 PA SPGAMUNEX INJ 10% BRAND TIER 02 PA SPGAMUNEX‐C INJ 10GM/100 BRAND TIER 03 SPGAMUNEX‐C INJ 1GM/10ML BRAND TIER 03 SPGAMUNEX‐C INJ 2.5GM/25 BRAND TIER 03 SPGAMUNEX‐C INJ 20GM/200 BRAND TIER 03 SPGAMUNEX‐C INJ 5GM/50ML BRAND TIER 03 SPHEPAGAM B INJ BRAND TIER 03 SPHEPAGAM B INJ GENERIC TIER 01 SPHIZENTRA INJ 1GM/5ML BRAND TIER 02 PA SPHIZENTRA INJ 2GM/10ML BRAND TIER 02 PA SPHIZENTRA INJ 4GM/20ML BRAND TIER 02 PA SPKey: 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= DrugExclusion253
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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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