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 StatusSULFONYLUREAS GLYBURID MCR TAB 6MG GENERIC TIER 01GLYBURIDE TAB 1.25MG GENERIC TIER 01GLYBURIDE TAB 2.5MG GENERIC TIER 01GLYBURIDE TAB 5MG GENERIC TIER 01GLYCRON TAB 1.5MG GENERIC TIER 01GLYCRON TAB 3MG GENERIC TIER 01GLYCRON TAB 4.5MG BRAND TIER 03GLYCRON TAB 6MG GENERIC TIER 01GLYNASE TAB 1.5MG Brand‐O TIER 03 PAGLYNASE TAB 3MG Brand‐O TIER 03 PAGLYNASE TAB 6MG Brand‐O TIER 03 PAMETAGLIP TAB 2.5‐250M Brand‐O TIER 03 PATOLAZAMIDE TAB 250MG GENERIC TIER 01TOLAZAMIDE TAB 500MG GENERIC TIER 01TOLBUTAMIDE TAB 500MG GENERIC TIER 01TETRACYCLINES ADOXA CAP 150MG Brand‐O TIER 03 PAADOXA TAB 100MG Brand‐O TIER 03 PAADOXA TAB 50MG Brand‐O TIER 03 PAADOXA TAB 75MG Brand‐O TIER 03 PAADOXA PAK 1/ TAB 100MG Brand‐O TIER 03 PAADOXA PAK 1/ TAB 150MG Brand‐O TIER 03 PAADOXA PAK 2/ TAB 100MG Brand‐O TIER 03 PAALODOX KIT 20MG BRAND TIER 99 DEAVIDOXY TAB 100MG GENERIC TIER 01AVIDOXY DK KIT BRAND TIER 03CHLORTETRACY CRY HCL GENERIC TIER 99 DEDEMECLOCYCL TAB 150MG GENERIC TIER 01DEMECLOCYCL TAB 300MG GENERIC TIER 01DORYX TAB 100MG Brand‐O TIER 03 PADORYX TAB 150MG BRAND TIER 03DOXYCYC MONO CAP 100MG GENERIC TIER 01DOXYCYC MONO CAP 50MG GENERIC TIER 01DOXYCYC MONO TAB 100MG GENERIC TIER 01DOXYCYC MONO TAB 150MG GENERIC TIER 01DOXYCYC MONO TAB 50MG GENERIC TIER 01DOXYCYC MONO TAB 75MG GENERIC TIER 01DOXYCYCL HYC CAP 100MG GENERIC TIER 01DOXYCYCL HYC CAP 50MG GENERIC TIER 01DOXYCYCL HYC INJ 100MG 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= DrugExclusion263