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 WESTHROID TAB 130MG GENERIC TIER 01WESTHROID TAB 146.25MG BRAND TIER 03WESTHROID TAB 16.25MG BRAND TIER 03WESTHROID TAB 162.50MG BRAND TIER 03WESTHROID TAB 195MG BRAND TIER 03WESTHROID TAB 260MG BRAND TIER 03WESTHROID TAB 32.5MG GENERIC TIER 01WESTHROID TAB 325MG BRAND TIER 03WESTHROID TAB 48.75MG BRAND TIER 03WESTHROID TAB 65MG GENERIC TIER 01WESTHROID TAB 81.25MG BRAND TIER 03WESTHROID TAB 97.5MG BRAND TIER 03THYROID FUNCTION IODOPEN INJ 100MCG BRAND TIER 03SODIUM IODID CAP I‐123 GENERIC TIER 99 DETHYROGEN INJ 1.1MG BRAND TIER 03 SPTOXOIDS ADACEL INJ BRAND TIER 03BOOSTRIX INJ BRAND TIER 03DAPTACEL INJ BRAND TIER 03DECAVAC INJ 5‐2LF GENERIC TIER 01DIP/TET PED INJ 25‐5LFU GENERIC TIER 01DIP/TET PED INJ 6.7‐5LF GENERIC TIER 01INFANRIX INJ BRAND TIER 03KINRIX INJ BRAND TIER 99 DETENIVAC INJ 5‐2LF BRAND TIER 03TET/DIP TOX INJ 2‐2 LF GENERIC TIER 01TETANUS TOX INJ 5LF ADS GENERIC TIER 01TRIHIBIT KIT P/F BRAND TIER 03TRIPEDIA SUS P/F BRAND TIER 03TRICHINOSIS TRICHOPHYTON INJ 1:200 GENERIC TIER 01TRICHOPHYTON INJ 1:500 BRAND TIER 03TRYCYCLICS & OTHER NOREPINEPH.‐RU INHIB AMITRIPTYLIN TAB 100MG GENERIC TIER 01AMITRIPTYLIN TAB 10MG GENERIC TIER 01AMITRIPTYLIN TAB 150MG GENERIC TIER 01AMITRIPTYLIN TAB 25MG GENERIC TIER 01AMITRIPTYLIN TAB 50MG GENERIC TIER 01AMITRIPTYLIN TAB 75MG GENERIC TIER 01AMOXAPINE TAB 100MG GENERIC TIER 01AMOXAPINE TAB 150MG GENERIC TIER 01AMOXAPINE TAB 25MG 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= DrugExclusion271