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 StatusVITAMIN D CALCIJEX INJ 1MCG/ML Brand‐O TIER 03 PACALCITRIOL CAP 0.25MCG GENERIC TIER 01CALCITRIOL CAP 0.5MCG GENERIC TIER 01CALCITRIOL INJ 1MCG/ML GENERIC TIER 01CALCITRIOL SOL 1MCG/ML GENERIC TIER 01DECARA CAP 25000 IU BRAND TIER 03DRISDOL CAP 50000UNT Brand‐O TIER 03 PAERGOCALCIFER CAP 50000UNT GENERIC TIER 01HECTOROL CAP 0.5MCG BRAND TIER 02HECTOROL CAP 1MCG BRAND TIER 02HECTOROL CAP 2.5MCG BRAND TIER 02HECTOROL INJ 2MCG/ML BRAND TIER 03HECTOROL INJ 4MCG/2ML BRAND TIER 03ROCALTROL CAP 0.25MCG Brand‐O TIER 03 PAROCALTROL CAP 0.5MCG Brand‐O TIER 03 PAROCALTROL SOL 1MCG/ML Brand‐O TIER 03 PAVITAMIN D CAP 50000UNT GENERIC TIER 01ZEMPLAR CAP 1MCG BRAND TIER 02ZEMPLAR CAP 2MCG BRAND TIER 02ZEMPLAR CAP 4MCG BRAND TIER 02ZEMPLAR INJ 2MCG/ML BRAND TIER 03ZEMPLAR INJ 5MCG/ML BRAND TIER 03VITAMIN E WHEAT GERM OIL GENERIC TIER 01VITAMIN K ACTIVITY MEPHYTON TAB 5MG BRAND TIER 02PHYTONADIONE INJ 1MG/0.5 GENERIC TIER 01VITAMIN K1 INJ 10MG/ML GENERIC TIER 01VITAMIN K1 INJ 1MG/0.5 GENERIC TIER 01ANTIFLATULENTS SIMETHICONE LIQ GENERIC TIER 99 DEBASIC POWDERS AND DEMULCENTS BENZOIN CMPD TIN GENERIC TIER 01BENZOIN TIN NF GENERIC TIER 01DETERGENTS GREEN SOAP TIN 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= DrugExclusion280