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 StatusTHYROID AGENTS ARMOUR THYRO TAB 300MG BRAND TIER 03ARMOUR THYRO TAB 30MG Brand‐O TIER 03 PAARMOUR THYRO TAB 60MG Brand‐O TIER 03 PAARMOUR THYRO TAB 90MG Brand‐O TIER 03 PACYTOMEL TAB 25MCG Brand‐O TIER 03 PACYTOMEL TAB 50MCG Brand‐O TIER 03 PACYTOMEL TAB 5MCG Brand‐O TIER 03 PALEVOTHROID TAB 100MCG GENERIC TIER 01LEVOTHROID TAB 112MCG GENERIC TIER 01LEVOTHROID TAB 125MCG GENERIC TIER 01LEVOTHROID TAB 137MCG GENERIC TIER 01LEVOTHROID TAB 150MCG GENERIC TIER 01LEVOTHROID TAB 175MCG GENERIC TIER 01LEVOTHROID TAB 200MCG GENERIC TIER 01LEVOTHROID TAB 25MCG GENERIC TIER 01LEVOTHROID TAB 300MCG GENERIC TIER 01LEVOTHROID TAB 50MCG GENERIC TIER 01LEVOTHROID TAB 75MCG GENERIC TIER 01LEVOTHROID TAB 88MCG GENERIC TIER 01LEVOTHYROXIN INJ 100MCG GENERIC TIER 01LEVOTHYROXIN INJ 200MCG GENERIC TIER 01LEVOTHYROXIN INJ 500MCG GENERIC TIER 01LEVOTHYROXIN TAB 100MCG GENERIC TIER 01LEVOTHYROXIN TAB 112MCG GENERIC TIER 01LEVOTHYROXIN TAB 125MCG GENERIC TIER 01LEVOTHYROXIN TAB 137MCG GENERIC TIER 01LEVOTHYROXIN TAB 150MCG GENERIC TIER 01LEVOTHYROXIN TAB 175MCG GENERIC TIER 01LEVOTHYROXIN TAB 200MCG GENERIC TIER 01LEVOTHYROXIN TAB 25MCG GENERIC TIER 01LEVOTHYROXIN TAB 300MCG GENERIC TIER 01LEVOTHYROXIN TAB 50MCG GENERIC TIER 01LEVOTHYROXIN TAB 75MCG GENERIC TIER 01LEVOTHYROXIN TAB 88MCG GENERIC TIER 01LEVOXYL TAB 100MCG GENERIC TIER 01LEVOXYL TAB 112MCG GENERIC TIER 01LEVOXYL TAB 125MCG GENERIC TIER 01LEVOXYL TAB 137MCG GENERIC TIER 01LEVOXYL TAB 150MCG 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= DrugExclusion268
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusTHYROID AGENTS LEVOXYL TAB 175MCG GENERIC TIER 01LEVOXYL TAB 200MCG GENERIC TIER 01LEVOXYL TAB 25MCG GENERIC TIER 01LEVOXYL TAB 50MCG GENERIC TIER 01LEVOXYL TAB 75MCG GENERIC TIER 01LEVOXYL TAB 88MCG GENERIC TIER 01LIOTHYRONINE INJ 10MCG/ML GENERIC TIER 01LIOTHYRONINE TAB 25MCG GENERIC TIER 01LIOTHYRONINE TAB 50MCG GENERIC TIER 01LIOTHYRONINE TAB 5MCG GENERIC TIER 01NATURE THROI TAB 162.5MG BRAND TIER 03NATURE‐THROI TAB 113.75MG BRAND TIER 03NATURE‐THROI TAB 130MG GENERIC TIER 01NATURE‐THROI TAB 146.25MG BRAND TIER 03NATURE‐THROI TAB 16.25MG GENERIC TIER 01NATURE‐THROI TAB 195MG GENERIC TIER 01NATURE‐THROI TAB 260MG BRAND TIER 03NATURE‐THROI TAB 32.5MG GENERIC TIER 01NATURE‐THROI TAB 325MG BRAND TIER 03NATURE‐THROI TAB 48.75MG BRAND TIER 03NATURE‐THROI TAB 65MG GENERIC TIER 01NATURE‐THROI TAB 81.25MG BRAND TIER 03NATURE‐THROI TAB 97.5MG BRAND TIER 03NP THYROID TAB 30MG GENERIC TIER 01NP THYROID TAB 60MG GENERIC TIER 01NP THYROID TAB 90MG GENERIC TIER 01SYNTHROID TAB 100MCG Brand‐O TIER 02 PASYNTHROID TAB 112MCG Brand‐O TIER 02 PASYNTHROID TAB 125MCG Brand‐O TIER 02 PASYNTHROID TAB 137MCG Brand‐O TIER 02 PASYNTHROID TAB 150MCG Brand‐O TIER 02 PASYNTHROID TAB 175MCG Brand‐O TIER 02 PASYNTHROID TAB 200MCG Brand‐O TIER 02 PASYNTHROID TAB 25MCG Brand‐O TIER 02 PASYNTHROID TAB 300MCG Brand‐O TIER 02 PASYNTHROID TAB 50MCG Brand‐O TIER 02 PASYNTHROID TAB 75MCG Brand‐O TIER 02 PASYNTHROID TAB 88MCG Brand‐O TIER 02 PATHYROLAR‐1 TAB 60MG 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= DrugExclusion269
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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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