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 StatusANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) TOPICORT GEL 0.05% Brand‐O TIER 03 PATOPICORT OIN 0.05% BRAND TIER 03TOPICORT OIN 0.25% Brand‐O TIER 03 PATRIAMCIN/ORA PST 0.1% GENERIC TIER 01TRIAMCINOLON CRE 0.025% GENERIC TIER 01TRIAMCINOLON CRE 0.1% GENERIC TIER 01TRIAMCINOLON CRE 0.5% GENERIC TIER 01TRIAMCINOLON LOT 0.025% GENERIC TIER 01TRIAMCINOLON LOT 0.1% GENERIC TIER 01TRIAMCINOLON OIN 0.025% GENERIC TIER 01TRIAMCINOLON OIN 0.05% GENERIC TIER 01TRIAMCINOLON OIN 0.1% GENERIC TIER 01TRIAMCINOLON OIN 0.5% GENERIC TIER 01TRIAMCINOLON PST 0.1% GENERIC TIER 01TRIANEX OIN 0.05% GENERIC TIER 01TRIDERM CRE 0.1% GENERIC TIER 01U‐CORT CRE 1% GENERIC TIER 01ULTRAVATE CRE 0.05% Brand‐O TIER 03 PAULTRAVATE KIT Brand‐O TIER 03 PAULTRAVATE KIT PAC BRAND TIER 99 DEULTRAVATE OIN 0.05% Brand‐O TIER 03 PAULTRAVATE X KIT 0.05‐10% BRAND TIER 03VANOS CRE 0.1% BRAND TIER 03VANOXIDE HC KIT BRAND TIER 03VANOXIDE‐HC LOT 5‐0.5% BRAND TIER 03VERDESO AER 0.05% BRAND TIER 03WESTCORT OIN 0.2% Brand‐O TIER 03 PAHYDROCORT CRE 1% GENERIC TIER 99 DEALA CORT CRE 1% GENERIC TIER 99 DEPRAMOSONE CRE 1‐2.5% Brand‐O TIER 99 PA DEHYDROCORT OIN 1% GENERIC TIER 99 DEHYDROCORT/AB OIN 1% GENERIC TIER 99 DEANUSOL‐HC SUP 25MG Brand‐O TIER 99 PA DEPROCTOCORT SUP 30MG Brand‐O TIER 99 PA DEANTILIPEMIC AGENTS, MISCELLANEOUS LOVAZA CAP 1GM BRAND TIER 02 PANIASPAN TAB 1000 ER BRAND TIER 02NIASPAN TAB 500MG ER BRAND TIER 02NIASPAN TAB 750MG ER BRAND TIER 02VASCAZEN CAP 1GM BRAND TIER 03Key: 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= DrugExclusion38
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIMALARIALS ARALEN TAB 500MG Brand‐O TIER 03 PA QLATOVAQ/PROGU TAB 250‐100 GENERIC TIER 01ATOVAQ/PROGU TAB 62.5‐25 GENERIC TIER 01CHLOROQUINE TAB 250MG GENERIC TIER 01 QLCHLOROQUINE TAB 500MG GENERIC TIER 01 QLCOARTEM TAB 20‐120MG BRAND TIER 02DARAPRIM TAB 25MG BRAND TIER 02HYDROXYCHLOR TAB 200MG GENERIC TIER 01MALARONE TAB 250‐100 Brand‐O TIER 03 PAMALARONE TAB 62.5‐25 BRAND TIER 03MEFLOQUINE TAB 250MG GENERIC TIER 01PLAQUENIL TAB 200MG Brand‐O TIER 03 PAPRIMAQUINE TAB 26.3MG GENERIC TIER 01QUALAQUIN CAP 324MG GENERIC TIER 01QUININE SULF CAP 324MG GENERIC TIER 01ANTIMANIC AGENTS LITHIUM CARB CAP 150MG GENERIC TIER 01LITHIUM CARB CAP 300MG GENERIC TIER 01LITHIUM CARB CAP 600MG GENERIC TIER 01LITHIUM CARB TAB 300MG GENERIC TIER 01LITHIUM CARB TAB 300MG ER GENERIC TIER 01LITHIUM CARB TAB 450MG ER GENERIC TIER 01LITHIUM CITR SOL 8MEQ/5ML GENERIC TIER 01LITHOBID TAB 300MG CR Brand‐O TIER 03 PAANTIMIGRAINE AGENTS, MISCELLANEOUS CAFERGOT TAB 1‐100MG BRAND TIER 02EPIDRIN CAP GENERIC TIER 99 DEERGOTAM/CAFF TAB 1/100 GENERIC TIER 01ISOMETH/APAP CAP DICHLOR GENERIC TIER 99 DEISOMETH/CAFF TAB /APAP GENERIC TIER 99 DEMIGERGOT SUP 2/100 BRAND TIER 03MIGRAGESIC CAP IDA GENERIC TIER 99 DEMIGRAL TAB 130MG BRAND TIER 03MIGRALAM CAP GENERIC TIER 99 DENODOLOR CAP GENERIC TIER 99 DEPRODRIN TAB Brand‐O TIER 99 PA DEANTIMUSCARINICS/ANTISPASMODICS ANASPAZ TAB 0.125MG Brand‐O TIER 03 PAATROPEN INJ 0.25MG BRAND TIER 03ATROPEN INJ 0.5MG BRAND TIER 03ATROPEN INJ 1MG BRAND TIER 03ATROPEN INJ 2MG BRAND TIER 03Key: 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= DrugExclusion39
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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