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 StatusBARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) LUMINAL INJ 60MG/ML BRAND TIER 03NEMBUTAL INJ 50MG/ML BRAND TIER 03NEMBUTAL SOD INJ 50MG/ML BRAND TIER 03PHENOBARB ELX 20MG/5ML GENERIC TIER 01PHENOBARB INJ 130MG/ML GENERIC TIER 01PHENOBARB INJ 65MG/ML GENERIC TIER 01PHENOBARB SOL 20MG/5ML GENERIC TIER 01PHENOBARB TAB 100MG GENERIC TIER 01PHENOBARB TAB 15MG GENERIC TIER 01PHENOBARB TAB 16.2MG GENERIC TIER 01PHENOBARB TAB 30MG GENERIC TIER 01PHENOBARB TAB 32.4MG GENERIC TIER 01PHENOBARB TAB 60MG GENERIC TIER 01PHENOBARB TAB 64.8MG GENERIC TIER 01PHENOBARB TAB 97.2MG GENERIC TIER 01SECONAL CAP 100MG BRAND TIER 03BARBITURATES (GENERAL ANESTHETICS) BREVITAL SOD INJ 2.5GM BRAND TIER 03BREVITAL SOD INJ 500MG BRAND TIER 03PENTOTHAL INJ 1GM BRAND TIER 03PENTOTHAL INJ 250MG BRAND TIER 03PENTOTHAL INJ 400MG BRAND TIER 03PENTOTHAL INJ 500MG BRAND TIER 03BASIC LOTIONS AND LINIMENTS AMMONIUM LAC CRE 12% GENERIC TIER 01COCOA BUTTER MIS GENERIC TIER 99 DEEUCALYPTUS OIL GENERIC TIER 01HYALURONATE GEL 0.2% GENERIC TIER 01HYGEL GEL 0.2% GENERIC TIER 01HYLIRA GEL 0.2% Brand‐O TIER 03 PAHYLIRA LOT 0.1% BRAND TIER 03LAC‐HYDRIN CRE 12% Brand‐O TIER 03 PALAC‐HYDRIN LOT 12% Brand‐O TIER 03 PALACLOTION LOT 12% GENERIC TIER 01LACTIC ACID LOT 10% GENERIC TIER 01MEDROX‐RX OIN BRAND TIER 03METHYL SALIC LIQ GENERIC TIER 01NEOSALUS LOT BRAND TIER 03SHEA BUTTER MIS GENERIC TIER 99 DESHEA BUTTER MIS ORGANIC GENERIC TIER 99 DESTEARYL MIS ALCOHOL GENERIC TIER 99 DEKey: 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= DrugExclusion66