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 StatusTHIAZOLIDINEDIONES PIOGLITA/MET TAB 15‐850MG GENERIC TIER 01PIOGLITAZONE TAB 15MG GENERIC TIER 01PIOGLITAZONE TAB 30MG GENERIC TIER 01PIOGLITAZONE TAB 45MG GENERIC TIER 01THIOXANTHENES NAVANE CAP 10MG Brand‐O TIER 03 PANAVANE CAP 20MG BRAND TIER 03NAVANE CAP 2MG Brand‐O TIER 03 PATHIOTHIXENE CAP 10MG GENERIC TIER 01THIOTHIXENE CAP 1MG GENERIC TIER 01THIOTHIXENE CAP 2MG GENERIC TIER 01THIOTHIXENE CAP 5MG GENERIC TIER 01THIRD GENERATION CEPHALOSPORINS CEDAX CAP 400MG BRAND TIER 03CEDAX SUS 180/5ML BRAND TIER 03CEDAX SUS 90MG/5ML BRAND TIER 03CEFDINIR CAP 300MG GENERIC TIER 01CEFDINIR SUS 125/5ML GENERIC TIER 01CEFDINIR SUS 250/5ML GENERIC TIER 01CEFDITOREN TAB 200MG GENERIC TIER 01CEFDITOREN TAB 400MG GENERIC TIER 01CEFOTAXIME INJ 10GM GENERIC TIER 01CEFOTAXIME INJ 1GM GENERIC TIER 01CEFOTAXIME INJ 20GM GENERIC TIER 01CEFOTAXIME INJ 2GM GENERIC TIER 01CEFOTAXIME INJ 500MG GENERIC TIER 01CEFPODO PROX SUS 100/5ML GENERIC TIER 01CEFPODO PROX SUS 50MG/5ML GENERIC TIER 01CEFPODOXIME TAB 100MG GENERIC TIER 01CEFPODOXIME TAB 200MG GENERIC TIER 01CEFTAZIDIME INJ 100GM GENERIC TIER 01CEFTAZIDIME INJ 1GM GENERIC TIER 01CEFTAZIDIME INJ 2GM GENERIC TIER 01CEFTAZIDIME INJ 500MG GENERIC TIER 01CEFTAZIDIME INJ 6GM GENERIC TIER 01CEFTAZIDIME/ SOL D5W 1GM GENERIC TIER 01CEFTAZIDIME/ SOL D5W 2GM GENERIC TIER 01CEFTRIAX/DEX INJ 1GM GENERIC TIER 01CEFTRIAX/DEX INJ 2GM GENERIC TIER 01CEFTRIAXONE INJ 10GM GENERIC TIER 01CEFTRIAXONE INJ 1GM 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= DrugExclusion266
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHIRD GENERATION CEPHALOSPORINS CEFTRIAXONE INJ 250MG GENERIC TIER 01CEFTRIAXONE INJ 2GM GENERIC TIER 01CEFTRIAXONE INJ 500MG GENERIC TIER 01CEFTRIAXONE/ INJ DEX 1GM GENERIC TIER 01CEFTRIAXONE/ INJ DEX 2GM GENERIC TIER 01CLAFORAN INJ 10GM Brand‐O TIER 03 PACLAFORAN INJ 1GM Brand‐O TIER 03 PACLAFORAN INJ 2GM Brand‐O TIER 03 PACLAFORAN INJ 500MG Brand‐O TIER 03 PACLAFORAN/D5W INJ 1GM BRAND TIER 03CLAFORAN/D5W INJ 2GM BRAND TIER 03FORTAZ INJ 1GM BRAND TIER 03FORTAZ INJ 2GM Brand‐O TIER 03 PAFORTAZ INJ 500MG BRAND TIER 03FORTAZ INJ 6GM Brand‐O TIER 03 PAROCEPHIN INJ 1GM Brand‐O TIER 03 PAROCEPHIN INJ 500MG Brand‐O TIER 03 PASPECTRACEF TAB 200MG BRAND TIER 03SPECTRACEF TAB 400MG BRAND TIER 03SUPRAX SUS 100/5ML BRAND TIER 03SUPRAX SUS 200/5ML BRAND TIER 03SUPRAX TAB 400MG BRAND TIER 03TAZICEF INJ 1GM GENERIC TIER 01TAZICEF INJ 1GM/50ML BRAND TIER 03TAZICEF INJ 2GM GENERIC TIER 01TAZICEF INJ 6GM GENERIC TIER 01SUPRAX CHW 100MG BRAND TIER 03SUPRAX CHW 200MG BRAND TIER 03THROMBOLYTIC AGENTS ACTIVASE INJ 100MG BRAND TIER 03ACTIVASE INJ 50MG BRAND TIER 03CATHFLO ACTI INJ VASE BRAND TIER 03KINLYTIC INJ 250000 BRAND TIER 03RETAVASE INJ BRAND TIER 03RETAVASE INJ HALF‐KIT BRAND TIER 03TNKASE KIT 50MG BRAND TIER 03THYROID AGENTS ARMOUR THYRO TAB 120MG BRAND TIER 03ARMOUR THYRO TAB 15MG BRAND TIER 03ARMOUR THYRO TAB 180MG BRAND TIER 03ARMOUR THYRO TAB 240MG 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= DrugExclusion267
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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