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 HYOSCYAMINE TAB 0.375 ER GENERIC TIER 01HYOSCYAMINE TAB 0.375 SR GENERIC TIER 01HYOSYNE DRO 0.125/ML GENERIC TIER 01HYOSYNE ELX 0.125/5 GENERIC TIER 01IPRATROPIUM SOL 0.02%INH GENERIC TIER 01IPRATROPIUM SPR 0.03% GENERIC TIER 01IPRATROPIUM SPR 0.06% GENERIC TIER 01LEVBID TAB 0.375 ER Brand‐O TIER 02 PALEVSIN INJ 0.5MG/ML BRAND TIER 03LEVSIN TAB 0.125MG Brand‐O TIER 03 PALEVSIN/SL SUB 0.125MG Brand‐O TIER 03 PAMETHSCOPOLAM TAB 2.5MG GENERIC TIER 01METHSCOPOLAM TAB 5MG GENERIC TIER 01NULEV TAB 0.125MG GENERIC TIER 01OSCIMIN SUB 0.125MG GENERIC TIER 01OSCIMIN TAB 0.125MG GENERIC TIER 01OSCIMIN SR TAB 0.375MG GENERIC TIER 01PAMINE TAB 2.5MG Brand‐O TIER 03 PAPAMINE FORTE TAB 5MG Brand‐O TIER 03 PAPAMINE FQ KIT BRAND TIER 03PROPANTHELIN TAB 15MG GENERIC TIER 01QUADRAPAX ELX GENERIC TIER 99 DEROBINUL INJ 0.2MG/ML Brand‐O TIER 03 PAROBINUL TAB 1MG Brand‐O TIER 03 PAROBINUL FORT TAB 2MG Brand‐O TIER 03 PASAL‐TROPINE TAB 0.4MG BRAND TIER 99 DESCOPOLAMINE INJ 0.4MG/ML GENERIC TIER 01SE‐DONNA ELX PB HYOS GENERIC TIER 99 DESIMETYL ELX BRAND TIER 03SPIRIVA CAP HANDIHLR BRAND TIER 02 QLSYMAX DUOTAB TAB Brand‐O TIER 03 PASYMAX FASTAB TAB 0.125MG GENERIC TIER 01SYMAX‐SL SUB 0.125MG GENERIC TIER 01SYMAX‐SR TAB 0.375MG GENERIC TIER 01TUDORZA PRES AER 400/ACT BRAND TIER 03LIBRAX CAP 5‐2.5MG Brand‐O TIER 99 PA DEDONNATAL TAB Brand‐O TIER 99 PA DEDONNATAL ELX Brand‐O TIER 99 PA DEANTIMYCOBACTERIALS, MISCELLANEOUS DAPSONE TAB 100MG 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= DrugExclusion41