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 StatusANTIMUSCARINICS/ANTISPASMODICS ATROPINE SUL INJ 0.05MG/1 GENERIC TIER 01ATROPINE SUL INJ 0.1MG/ML GENERIC TIER 01ATROPINE SUL INJ 0.4/0.5 GENERIC TIER 01ATROPINE SUL INJ 0.4MG/ML GENERIC TIER 01ATROPINE SUL INJ 1MG/ML GENERIC TIER 01ATROVENT HFA AER 17MCG BRAND TIER 02 QLATROVENT NAS SOL 0.03% Brand‐O TIER 03 PAATROVENT NAS SOL 0.06% Brand‐O TIER 03 PABELLA ALK/PB TAB 16.2MG GENERIC TIER 99 DEBELLA/OPIUM SUP 16.2‐30 GENERIC TIER 01BELLA/OPIUM SUP 16.2‐60 GENERIC TIER 01BELLADONNA TIN 30/100ML GENERIC TIER 01BENTYL CAP 10MG Brand‐O TIER 03 PABENTYL INJ 10MG/ML BRAND TIER 03BENTYL SYP 10MG/5ML Brand‐O TIER 03 PABENTYL TAB 20MG Brand‐O TIER 03 PACANTIL TAB 25MG BRAND TIER 03CHLORD/CLIDI CAP 5‐2.5MG GENERIC TIER 99 DECOLIDROPS DRO 0.125/ML GENERIC TIER 01CUVPOSA SOL 1MG/5ML BRAND TIER 03DICYCLOMINE CAP 10MG GENERIC TIER 01DICYCLOMINE SOL 10MG/5ML GENERIC TIER 01DICYCLOMINE TAB 20MG GENERIC TIER 01DIGEX NF CAP Brand‐O TIER 03 PADONNATAL TAB EXTENTAB BRAND TIER 99 DEED‐SPAZ TAB 0.125MG GENERIC TIER 01GASTRINEX NF CAP GENERIC TIER 01GLYCOPYRROL INJ 0.2MG/ML GENERIC TIER 01GLYCOPYRROL TAB 1MG GENERIC TIER 01GLYCOPYRROL TAB 2MG GENERIC TIER 01HYOMAX TAB 0.125MG GENERIC TIER 01HYOMAX‐DT TAB GENERIC TIER 01HYOMAX‐FT TAB 0.125MG GENERIC TIER 01HYOMAX‐SL SUB 0.125MG GENERIC TIER 01HYOMAX‐SR TAB 0.375MG GENERIC TIER 01HYOSCYAMINE DRO 0.125/ML GENERIC TIER 01HYOSCYAMINE ELX 0.125/5 GENERIC TIER 01HYOSCYAMINE SUB 0.125MG GENERIC TIER 01HYOSCYAMINE TAB 0.125MG 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= DrugExclusion40