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 StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. VANIQA CRE 13.9% BRAND TIER 03VASOLEX OIN GENERIC TIER 99 DEVECTICAL OIN 3MCG/GM BRAND TIER 02VELTIN GEL BRAND TIER 02 PAVENELEX OIN BRAND TIER 03VEREGEN OIN 15% BRAND TIER 03VOLTAREN GEL 1% BRAND TIER 03 PA QLXCLAIR CRE GENERIC TIER 01ZIANA GEL BRAND TIER 03 PAZITHRANOL SHA 1% BRAND TIER 03ZITHRANOL‐RR CRE 1.2% BRAND TIER 03ZYCLARA CRE 3.75% BRAND TIER 03 PA QLZYCLARA PUMP CRE 2.5% BRAND TIER 03 PAZYCLARA PUMP CRE 3.75% BRAND TIER 03 PA QLGRANULEX AER Brand‐O TIER 99 PA DEXENADERM OIN Brand‐O TIER 99 PA DEGLYCOLIC ACD SOL 70% GENERIC TIER 01CARRASYN GEL DRESSING BRAND TIER 03PARAFFIN MIS GENERIC TIER 99 DESOMATOTROPIN AGONISTS EGRIFTA INJ 1MG BRAND TIER 03 PA QL SPEGRIFTA SOL 2MG BRAND TIER 03 PAGENOTROPIN INJ 0.2MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.4MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.6MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.8MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.2MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.4MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.6MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.8MG BRAND TIER 03 PA SPGENOTROPIN INJ 12MG BRAND TIER 03 PA SPGENOTROPIN INJ 1MG BRAND TIER 03 PA SPGENOTROPIN INJ 2MG BRAND TIER 03 PA SPGENOTROPIN INJ 5MG BRAND TIER 03 PA SPHUMATROPE INJ 12MG BRAND TIER 03 PA SPHUMATROPE INJ 24MG BRAND TIER 03 PA SPHUMATROPE INJ 5MG BRAND TIER 03 PA SPHUMATROPE INJ 6MG BRAND TIER 03 PA SPINCRELEX INJ 40MG/4ML BRAND TIER 03 PA SPNORDITROPIN INJ 10/1.5ML 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= DrugExclusion260
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSOMATOTROPIN AGONISTS NORDITROPIN INJ 15/1.5ML BRAND TIER 02 PA SPNORDITROPIN INJ 30/3ML BRAND TIER 02 PA SPNORDITROPIN INJ 5/1.5ML BRAND TIER 02 PA SPNUTROPIN INJ 10MG BRAND TIER 02 PA SPNUTROPIN AQ INJ 10MG/2ML BRAND TIER 02 PA SPNUTROPIN AQ INJ 20MG/2ML BRAND TIER 02 PA SPNUTROPIN AQ INJ NUSPIN 5 BRAND TIER 02 PA SPOMNITROPE INJ 10/1.5ML BRAND TIER 03 PA SPOMNITROPE INJ 5.8MG BRAND TIER 03 PA SPOMNITROPE INJ 5/1.5ML BRAND TIER 03 PA SPSAIZEN INJ 5MG BRAND TIER 03 PA SPSAIZEN INJ 8.8MG BRAND TIER 03 PA SPSEROSTIM INJ 4MG BRAND TIER 03 PA SPSEROSTIM INJ 5MG BRAND TIER 03 PA SPSEROSTIM INJ 6MG BRAND TIER 03 PA SPTEV‐TROPIN INJ 5MG BRAND TIER 03 PA SPZORBTIVE INJ 8.8MG BRAND TIER 03 PA SPSOMATOTROPIN ANTAGONISTS SOMAVERT INJ 10MG BRAND TIER 02 SPSOMAVERT INJ 15MG BRAND TIER 02 SPSOMAVERT INJ 20MG BRAND TIER 02 SPSTREPTOGRAMINS SYNERCID INJ 500MG BRAND TIER 03SUCCINIMIDES CELONTIN CAP 300MG BRAND TIER 02ETHOSUXIMIDE CAP 250MG GENERIC TIER 01ETHOSUXIMIDE SOL 250/5ML GENERIC TIER 01ZARONTIN CAP 250MG Brand‐O TIER 03 PAZARONTIN SOL 250/5ML Brand‐O TIER 03 PASULFONAMIDES (SYSTEMIC) AZULFIDINE TAB 500MG Brand‐O TIER 03 PAAZULFIDINE TAB 500MG EN Brand‐O TIER 03 PABACTRIM TAB 400‐80MG Brand‐O TIER 03 PABACTRIM DS TAB 800‐160 Brand‐O TIER 03 PASEPTRA DS TAB 800‐160 Brand‐O TIER 03 PASMZ/TMP DS TAB 800‐160 GENERIC TIER 01SMZ‐TMP INJ 400‐80/5 GENERIC TIER 01SMZ‐TMP SUS GENERIC TIER 01SMZ‐TMP SUS 200‐40/5 GENERIC TIER 01SMZ‐TMP TAB 400‐80MG GENERIC TIER 01SULFADIAZINE TAB 500MG GENERIC TIER 01SULFASALAZIN TAB 500MG GENERIC TIER 01SULFASALAZIN TAB 500MG DR 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= DrugExclusion261
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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