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 StatusTETRACYCLINES DOXYCYCL HYC TAB 100MG GENERIC TIER 01DOXYCYCL HYC TAB 150MG GENERIC TIER 01DOXYCYCL HYC TAB 75MG GENERIC TIER 01DOXYCYCLINE CAP 150MG GENERIC TIER 01DOXYCYCLINE CAP 75MG GENERIC TIER 01DOXYCYCLINE TAB 20MG GENERIC TIER 01DYNACIN TAB 100MG Brand‐O TIER 03 PADYNACIN TAB 50MG Brand‐O TIER 03 PADYNACIN TAB 75MG Brand‐O TIER 03 PAMINOCIN CAP 100MG Brand‐O TIER 03 PAMINOCIN CAP 50MG Brand‐O TIER 03 PAMINOCIN INJ 100MG BRAND TIER 03MINOCIN KIT 100MG BRAND TIER 03MINOCIN KIT 50MG BRAND TIER 03MINOCYCLINE CAP 100MG GENERIC TIER 01MINOCYCLINE CAP 50MG GENERIC TIER 01MINOCYCLINE CAP 75MG GENERIC TIER 01MINOCYCLINE TAB 100MG GENERIC TIER 01MINOCYCLINE TAB 50MG GENERIC TIER 01MINOCYCLINE TAB 75MG GENERIC TIER 01MONODOX CAP 100MG Brand‐O TIER 03 PAMONODOX CAP 50MG Brand‐O TIER 03 PAMONODOX CAP 75MG Brand‐O TIER 03 PAMORGIDOX CAP 1X100MG GENERIC TIER 01MORGIDOX CAP 2X100MG GENERIC TIER 01MORGIDOX KIT 1X100MG BRAND TIER 03MORGIDOX KIT 2X100MG BRAND TIER 03NUTRIDOX KIT BRAND TIER 03OCUDOX KIT BRAND TIER 03ORAXYL CAP 20MG BRAND TIER 03TETRACYCLINE CAP 250MG GENERIC TIER 01TETRACYCLINE CAP 500MG GENERIC TIER 01VIBRAMYCIN CAP 100MG Brand‐O TIER 03 PAVIBRAMYCIN SUS 25MG/5ML BRAND TIER 02VIBRAMYCIN SYP 50MG/5ML BRAND TIER 03THIAZIDE DIURETICS CHLOROTHIAZ INJ 500MG GENERIC TIER 01CHLOROTHIAZ TAB 250MG GENERIC TIER 01CHLOROTHIAZ TAB 500MG GENERIC TIER 01DIURIL SUS 250/5ML 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= DrugExclusion264