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 StatusADRENALS DEPO‐MEDROL INJ 20MG/ML BRAND TIER 03DEPO‐MEDROL INJ 40MG/ML Brand‐O TIER 03 PADEPO‐MEDROL INJ 80MG/ML Brand‐O TIER 03 PADEXAMETH PHO INJ 10MG/ML GENERIC TIER 01DEXAMETH PHO INJ 4MG/ML GENERIC TIER 01DEXAMETHASON CON 1MG/ML BRAND TIER 03DEXAMETHASON ELX 0.5/5ML GENERIC TIER 01DEXAMETHASON SOL 0.5/5ML GENERIC TIER 01DEXAMETHASON TAB 0.5MG GENERIC TIER 01DEXAMETHASON TAB 0.75MG GENERIC TIER 01DEXAMETHASON TAB 1.5MG GENERIC TIER 01DEXAMETHASON TAB 1MG GENERIC TIER 01DEXAMETHASON TAB 2MG GENERIC TIER 01DEXAMETHASON TAB 4MG GENERIC TIER 01DEXAMETHASON TAB 6MG GENERIC TIER 01DEXPAK PAK 10 DAY BRAND TIER 03DEXPAK PAK 13 DAY BRAND TIER 03DEXPAK PAK 6 DAY BRAND TIER 03DULERA AER 100‐5MCG BRAND TIER 03 PA QLDULERA AER 200‐5MCG BRAND TIER 03 PA QLENTOCORT EC CAP 3MG/24HR Brand‐O TIER 03 PAFLO‐PRED SUS BRAND TIER 03FLOVENT DISK AER 100MCG BRAND TIER 02 QLFLOVENT DISK AER 250MCG BRAND TIER 02 QLFLOVENT DISK AER 50MCG BRAND TIER 02 QLFLOVENT HFA AER 110MCG BRAND TIER 02 QLFLOVENT HFA AER 220MCG BRAND TIER 02 QLFLOVENT HFA AER 44MCG BRAND TIER 02 QLFLUDROCORT TAB 0.1MG GENERIC TIER 01HYDROCORT TAB 10MG GENERIC TIER 01HYDROCORT TAB 20MG GENERIC TIER 01HYDROCORT TAB 5MG GENERIC TIER 01KENALOG‐10 INJ 10MG/ML BRAND TIER 03KENALOG‐40 INJ 40MG/ML BRAND TIER 03MEDROL PAK 4MG Brand‐O TIER 03 PAMEDROL TAB 16MG Brand‐O TIER 03 PAMEDROL TAB 2MG BRAND TIER 03MEDROL TAB 32MG Brand‐O TIER 03 PAMEDROL TAB 4MG Brand‐O TIER 03 PAKey: 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= DrugExclusion3