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 StatusANTIFULGALS(SKIN & MUCOUS MEMBRANE),MISC ALOQUIN GEL 1.25‐1% BRAND TIER 03BENSAL HP OIN BRAND TIER 03EXODERM LOT 25‐1% GENERIC TIER 01HALOTIN CRE 1% BRAND TIER 03KERR TRIPLE MIS DYE SWAB BRAND TIER 03THIOSULFATE CRY SODIUM GENERIC TIER 99 DETRIPLE DYE LIQ GENERIC TIER 01VERSICLEAR LOT GENERIC TIER 01BENZOIC ACID CRY GENERIC TIER 99 DEANTIFUNGALS (EENT) NATACYN SUS 5% OP BRAND TIER 02ANTIFUNGALS, MISCELLANEOUS GRIFULVIN V TAB 500MG BRAND TIER 03GRISEOFULVIN SUS 125/5ML GENERIC TIER 01GRIS‐PEG TAB 125MG BRAND TIER 03GRIS‐PEG TAB 250MG BRAND TIER 03ANTIGOUT AGENTS ALLOPURINOL INJ 500MG GENERIC TIER 01ALLOPURINOL TAB 100MG GENERIC TIER 01ALLOPURINOL TAB 300MG GENERIC TIER 01ALOPRIM INJ 500MG Brand‐O TIER 03 PACOLCHICINE TAB 0.6MG GENERIC TIER 01COLCRYS TAB 0.6MG BRAND TIER 02KRYSTEXXA INJ 8MG/ML BRAND TIER 02 PA SPULORIC TAB 40MG BRAND TIER 02 PAULORIC TAB 80MG BRAND TIER 02 PAZYLOPRIM TAB 100MG Brand‐O TIER 03 PAZYLOPRIM TAB 300MG Brand‐O TIER 03 PAANTIHEPARIN AGENTS PROTAMINE SU SOL 10MG/ML GENERIC TIER 01ANTIHISTAMINE DRUGS PHENER FORT SYP 25MG/5ML BRAND TIER 03ANTIHISTAMINES (GI DRUGS) ANTIVERT TAB 12.5MG Brand‐O TIER 03 PAANTIVERT TAB 25MG Brand‐O TIER 03 PAANTIVERT TAB 50MG BRAND TIER 03DIMENHYDRIN INJ 50MG/ML GENERIC TIER 01TIGAN CAP 300MG Brand‐O TIER 03 PATIGAN INJ 100MG/ML Brand‐O TIER 03 PATRIMETHOBENZ CAP 300MG GENERIC TIER 01TRIMETHOBENZ INJ 100MG/ML GENERIC TIER 01UNIVERT TAB 32MG GENERIC TIER 01MECLIZINE TAB 12.5MG GENERIC TIER 01MECLIZINE TAB 25MG GENERIC TIER 01ANTI‐INFLAMMATORY AGENTS (GI DRUGS) APRISO CAP 0.375GM BRAND TIER 02Key: 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= DrugExclusion32