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 StatusVACCINES INFLUENZA A INJ PF09H1N1 GENERIC TIER 01INFLUENZA A SPR 09 H1N1 GENERIC TIER 01IPOL INJ INACTIVE BRAND TIER 03IXIARO INJ BRAND TIER 99 DEJE‐VAX INJ BRAND TIER 03MENACTRA INJ BRAND TIER 03MENHIBRIX INJ BRAND TIER 03MENOMUNE INJ A/C/Y/W BRAND TIER 03MENVEO INJ BRAND TIER 03M‐M‐R II INJ LIVE BRAND TIER 03PEDIARIX INJ 0.5ML BRAND TIER 03PEDVAX HIB INJ BRAND TIER 03PENTACEL INJ BRAND TIER 99 DEPNEUMOVAX 23 INJ 25/0.5 BRAND TIER 03PNEUMOVAX 23 INJ 25/0.5 GENERIC TIER 01PREVNAR 13 INJ BRAND TIER 03PROQUAD INJ BRAND TIER 03RABAVERT INJ BRAND TIER 03RECOMBIVA HB INJ 10MCG/ML BRAND TIER 03RECOMBIVA HB INJ 5MCG/0.5 BRAND TIER 03RECOMBIVA‐HB INJ 40MCG/ML BRAND TIER 03ROTARIX SUS BRAND TIER 03ROTATEQ SUS BRAND TIER 99 DETHERACYS INJ BRAND TIER 03 SPTICE BCG INJ BRAND TIER 03 SPTWINRIX INJ BRAND TIER 03TYPHIM VI INJ BRAND TIER 03VAQTA INJ 25/0.5ML BRAND TIER 03VAQTA INJ 50UNT/ML BRAND TIER 03VARIVAX INJ BRAND TIER 03VIVOTIF BERN CAP EC BRAND TIER 03YF‐VAX INJ GENERIC TIER 01ZOSTAVAX INJ BRAND TIER 99 DEVASOCONSTRICTORS ADRENALIN SOL 1:1000 BRAND TIER 03AK‐CON SOL 0.1% OP GENERIC TIER 01ALTAFRIN SOL 10% OP GENERIC TIER 01ALTAFRIN SOL 2.5% OP GENERIC TIER 01MYDFRIN SOL 2.5% OP Brand‐O TIER 03 PANEOFRIN SOL 10% OP 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= DrugExclusion276
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusVASOCONSTRICTORS NEOFRIN SOL 2.5% OP GENERIC TIER 01PHENYLEPHRIN SOL 10% OP GENERIC TIER 01PHENYLEPHRIN SOL 2.5% OP GENERIC TIER 01TYZINE SOL 0.1% BRAND TIER 03TYZINE PED DRO 0.05% BRAND TIER 03VASODILATING AGENTS, MISCELLANEOUS ALPROSTADIL INJ 500MCG GENERIC TIER 01CAVERJECT INJ 20MCG BRAND TIER 99 DECAVERJECT INJ 40MCG BRAND TIER 99 DECAVERJECT KIT 10MCG BRAND TIER 99 DECAVERJECT KIT 20MCG BRAND TIER 99 DEDIPYRIDAMOLE INJ 5MG/ML GENERIC TIER 01DIPYRIDAMOLE TAB 25MG GENERIC TIER 01DIPYRIDAMOLE TAB 50MG GENERIC TIER 01DIPYRIDAMOLE TAB 75MG GENERIC TIER 01EDEX KIT 10MCG BRAND TIER 99 DEEDEX KIT 20MCG BRAND TIER 99 DEEDEX KIT 40MCG BRAND TIER 99 DEEPOPROSTENOL INJ 0.5MG GENERIC TIER 01 PA SPEPOPROSTENOL INJ 1.5MG GENERIC TIER 01 PA SPFLOLAN INJ 0.5MG Brand‐O TIER 02 PA SPFLOLAN INJ 1.5MG Brand‐O TIER 02 PA SPISOXSUPRINE TAB 10MG GENERIC TIER 99 DELETAIRIS TAB 10MG BRAND TIER 02 PA SPLETAIRIS TAB 5MG BRAND TIER 02 PA SPMUSE SUP 1000MCG BRAND TIER 99 DEMUSE SUP 125MCG BRAND TIER 99 DEMUSE SUP 250MCG BRAND TIER 99 DEMUSE SUP 500MCG BRAND TIER 99 DENATRECOR INJ 1.5MG BRAND TIER 03PAPAVERINE INJ 30MG/ML GENERIC TIER 01PAPAVERINE SOL 30MG/ML GENERIC TIER 01PERSANTINE TAB 25MG Brand‐O TIER 03 PAPERSANTINE TAB 50MG Brand‐O TIER 03 PAPERSANTINE TAB 75MG Brand‐O TIER 03 PAPROSTIN VR INJ 500MCG Brand‐O TIER 03 PAREMODULIN INJ 10MG/ML BRAND TIER 02 PA SPREMODULIN INJ 1MG/ML BRAND TIER 02 PA SPREMODULIN INJ 2.5MG/ML BRAND TIER 02 PA SPREMODULIN INJ 5MG/ML BRAND TIER 02 PA SPKey: 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= DrugExclusion277
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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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