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 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