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 StatusVASODILATING AGENTS, MISCELLANEOUS TRACLEER TAB 125MG BRAND TIER 02 PA SPTRACLEER TAB 62.5MG BRAND TIER 02 PA SPTYVASO SOL 0.6MG/ML BRAND TIER 02 PA SPTYVASO REFIL SOL 0.6MG/ML BRAND TIER 02 PA SPTYVASO START SOL 0.6MG/ML BRAND TIER 02 PA SPVELETRI INJ 0.5MG BRAND TIER 02 PA SPVELETRI INJ 1.5MG BRAND TIER 02 PA SPVELETRI INJ 1.5MG GENERIC TIER 01 PA SPVENTAVIS SOL 10MCG/ML BRAND TIER 02 PA SPVENTAVIS SOL 20MCG/ML BRAND TIER 02 PA SPVASOPRESSIN ANTAGONISTS SAMSCA TAB 15MG BRAND TIER 02 PA QLSAMSCA TAB 30MG BRAND TIER 02 PA QLVAPRISOL INJ BRAND TIER 99 DEVITAMIN A AQUASOL A INJ 50000/ML BRAND TIER 03VITAMIN B COMPLEX AIRAVITE TAB GENERIC TIER 99 DEALZ‐NAC TAB BRAND TIER 03AMINOBEZ POT POW GENERIC TIER 99 DEANIMI‐3 CAP Brand‐O TIER 03 PAANIMI‐3 CAP VIT D BRAND TIER 03B6 FOLIC ACD CAP GENERIC TIER 01B‐COMPLEX INJ GENERIC TIER 99 DEB‐COMPLEX INJ 100 GENERIC TIER 99 DEBP VIT 3 CAP GENERIC TIER 01CARDIOTEK‐RX TAB BRAND TIER 03CEREFOLIN TAB BRAND TIER 03CEREFOLIN TAB NAC BRAND TIER 03CYANOCOBALAM CRY GENERIC TIER 99 DECYANOCOBALAM INJ 1000MCG GENERIC TIER 01DEXPANTHENOL INJ 250MG/ML GENERIC TIER 01DIVISTA CAP BRAND TIER 99 DEFA‐B6‐B12 TAB GENERIC TIER 99 DEFABB TAB GENERIC TIER 99 DEFOLASTIN TAB GENERIC TIER 99 DEFOLBEE TAB GENERIC TIER 99 DEFOLBEE AR TAB BRAND TIER 03FOLBIC TAB GENERIC TIER 99 DEFOLCAPS TAB GENERIC TIER 99 DEFOLIC ACID INJ 5MG/ML GENERIC TIER 01FOLIC ACID TAB GENERIC TIER 99 DEKey: 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= DrugExclusion278