BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

More documents

Recommendations

Info

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusURINARY ANTI‐INFECTIVES HYOPHEN TAB GENERIC TIER 01MACROBID CAP 100MG Brand‐O TIER 03 PAMACRODANTIN CAP 100MG Brand‐O TIER 03 PAMACRODANTIN CAP 25MG BRAND TIER 03MACRODANTIN CAP 50MG Brand‐O TIER 03 PAMETHENAM HIP TAB 1GM GENERIC TIER 01METHENAM MAN TAB 1000MG GENERIC TIER 01METHENAM MAN TAB 1GM GENERIC TIER 01METHENAM MAN TAB 500MG GENERIC TIER 01MONUROL PAK GRANULES BRAND TIER 03NITROFUR MAC CAP 100MG GENERIC TIER 01NITROFUR MAC CAP 50MG GENERIC TIER 01NITROFURANTN CAP 100MG GENERIC TIER 01NITROFURANTN SUS 25MG/5ML GENERIC TIER 01PHOSPHASAL TAB GENERIC TIER 01PRIMSOL SOL 50MG/5ML BRAND TIER 03PROSED/DS TAB Brand‐O TIER 03 PATRIMETHOPRIM TAB 100MG GENERIC TIER 01UR N‐C TAB GENERIC TIER 01URELLE TAB BRAND TIER 03URETRON D/S TAB BRAND TIER 03URETRON D/S TAB GENERIC TIER 01UREX TAB 1GM Brand‐O TIER 03 PAURIBEL CAP 118MG BRAND TIER 03URIN D/S TAB GENERIC TIER 01UROGESIC‐ TAB BLUE Brand‐O TIER 03 PAUROQID #2 TAB BRAND TIER 03URYL TAB GENERIC TIER 01USTELL CAP GENERIC TIER 01UTA CAP 120MG GENERIC TIER 01UTICAP CAP GENERIC TIER 01UTIRA‐C TAB GENERIC TIER 01UTRONA‐C TAB GENERIC TIER 01VACCINES ACTHIB INJ BRAND TIER 03AFLURIA INJ 2009‐10 BRAND TIER 03AFLURIA INJ 2011‐12 BRAND TIER 03AFLURIA INJ 2012‐13 BRAND TIER 03AFLURIA INJ PF 10‐11 BRAND TIER 03AFLURIA INJ PF 11‐12 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= DrugExclusion274
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVACCINES AFLURIA INJ PF 12‐13 BRAND TIER 03AGRIFLU INJ 2010‐11 BRAND TIER 03BIOTHRAX INJ BRAND TIER 99 DECERVARIX INJ BRAND TIER 03 PACOMVAX INJ BRAND TIER 03ENGERIX‐B INJ 10/0.5ML BRAND TIER 03ENGERIX‐B INJ 20MCG/ML BRAND TIER 03FLUARIX INJ PF 10‐11 BRAND TIER 03FLUARIX INJ PF 11‐12 BRAND TIER 03FLUARIX INJ PF 12‐13 BRAND TIER 03FLULAVAL INJ 2010‐11 BRAND TIER 03FLULAVAL INJ 2011‐12 BRAND TIER 03FLULAVAL INJ 2012‐13 BRAND TIER 03FLUMIST NASA LIQ 2010‐11 BRAND TIER 03FLUMIST NASA LIQ 2011‐12 BRAND TIER 03FLUMIST NASA LIQ 2012‐13 BRAND TIER 03FLUVIRIN INJ 2010‐11 BRAND TIER 03FLUVIRIN INJ 2011‐12 BRAND TIER 03FLUVIRIN INJ 2012‐13 BRAND TIER 03FLUVIRIN INJ PF 11‐12 BRAND TIER 03FLUVIRIN INJ PF 12‐13 BRAND TIER 03FLUZONE INJ INTRADRM BRAND TIER 03FLUZONE INJ PF 10‐11 BRAND TIER 03FLUZONE INJ PF 11‐12 BRAND TIER 03FLUZONE INJ PF 12‐13 BRAND TIER 03FLUZONE HD INJ PF 10‐11 BRAND TIER 03FLUZONE HD INJ PF 11‐12 BRAND TIER 03FLUZONE HD INJ PF 12‐13 BRAND TIER 03FLUZONE PED/ INJ PF 10‐11 BRAND TIER 03FLUZONE PED/ INJ PF 11‐12 BRAND TIER 03FLUZONE PED/ INJ PF 12‐13 BRAND TIER 03FLUZONE SPLT INJ 2010‐11 BRAND TIER 03FLUZONE SPLT INJ 2011‐12 BRAND TIER 03FLUZONE SPLT INJ 2012‐13 BRAND TIER 03GARDASIL INJ BRAND TIER 03 PAHAVRIX INJ 1440UNIT BRAND TIER 03HAVRIX INJ 720UNIT BRAND TIER 03HIBERIX SOL 10‐25MCG BRAND TIER 99 DEIMOVAX RABIE INJ 2.5/ML 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= DrugExclusion275
Page 1 and 2:
BMC HealthNet Plan Drug List - Comm
Page 3 and 4:
AHFS Therapeutic Class Description
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225: AHFS Therapeutic Class Description
Page 280: AHFS Therapeutic Class Description
show all

BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?