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 PULMICORT SUS 0.5MG/2 Brand‐O TIER 03 PA QLPULMICORT SUS 1MG/2ML BRAND TIER 02 QLQVAR AER 40MCG BRAND TIER 02 QLQVAR AER 80MCG BRAND TIER 02 QLRAYOS TAB 1MG BRAND TIER 03RAYOS TAB 2MG BRAND TIER 03RAYOS TAB 5MG BRAND TIER 03SOLU‐CORTEF INJ 1000MG BRAND TIER 03SOLU‐CORTEF INJ 100MG Brand‐O TIER 03 PASOLU‐CORTEF INJ 250MG BRAND TIER 03SOLU‐CORTEF INJ 500MG BRAND TIER 03SOLU‐MEDROL INJ 125MG Brand‐O TIER 03 PASOLU‐MEDROL INJ 1GM Brand‐O TIER 03 PASOLU‐MEDROL INJ 2GM BRAND TIER 03SOLU‐MEDROL INJ 40MG Brand‐O TIER 03 PASOLU‐MEDROL INJ 500MG Brand‐O TIER 03 PASYMBICORT AER 160‐4.5 BRAND TIER 03 PA QLSYMBICORT AER 80‐4.5 BRAND TIER 03 PA QLVERIPRED 20 SOL 20MG/5ML BRAND TIER 03ZEMA‐PAK PAK 10 DAY GENERIC TIER 01ZEMA‐PAK PAK 13 DAY GENERIC TIER 01ZEMA‐PAK PAK 6 DAY GENERIC TIER 01ADRENOCORTICAL INSUFFICIENCY CORTROSYN INJ 0.25MG Brand‐O TIER 03 PACOSYNTROPIN INJ 0.25MG GENERIC TIER 01ALCOHOL DETERRENTS ANTABUSE TAB 250MG Brand‐O TIER 03 PAANTABUSE TAB 500MG Brand‐O TIER 03 PADISULFIRAM TAB 250MG GENERIC TIER 01DISULFIRAM TAB 500MG GENERIC TIER 01ALKALINIZING AGENTS CITRIC ACID/ SOL SOD CITR GENERIC TIER 01CITROLITH TAB BRAND TIER 03CYTRA K GRA CRYSTALS GENERIC TIER 01CYTRA‐2 SOL GENERIC TIER 01CYTRA‐3 SYP GENERIC TIER 01CYTRA‐K SOL GENERIC TIER 01K CITRATE SOL CITR ACD GENERIC TIER 01NEUT INJ 4% BRAND TIER 03ORACIT SOL BRAND TIER 03POLYCITRA‐K POW CRYSTALS Brand‐O TIER 03 PAPOT CITRATE TAB 1080MG 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= DrugExclusion5