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 StatusCALORIC AGENTS AMINOSYN II INJ 10% BRAND TIER 03AMINOSYN II INJ 15% Brand‐O TIER 03 PAAMINOSYN II INJ 4.25/D25 BRAND TIER 03AMINOSYN II INJ 5/D25 BRAND TIER 03AMINOSYN II INJ 7% BRAND TIER 03AMINOSYN II INJ 8.5% BRAND TIER 03AMINOSYN II INJ 8.5/LYTE GENERIC TIER 01AMINOSYN M INJ 3.5% BRAND TIER 03AMINOSYN‐HBC INJ 7% BRAND TIER 03AMINOSYN‐HF INJ 8% GENERIC TIER 01AMINOSYN‐PF INJ 10% BRAND TIER 03AMINOSYN‐PF INJ 7% BRAND TIER 03AMINOSYN‐RF INJ 5.2% BRAND TIER 03APPTRIM CAP BRAND TIER 99 DEAPPTRIM LIFE CAP BARIATRC BRAND TIER 99 DEAPPTRIM LIFE CAP OBESITY BRAND TIER 99 DEAPPTRIM‐D CAP BRAND TIER 99 DEAXONA POW BRAND TIER 03CESINEX SUS BRAND TIER 03CLINIMIX INJ 2.75/D5W BRAND TIER 03CLINIMIX INJ 4.25/D10 BRAND TIER 03CLINIMIX INJ 4.25/D10 GENERIC TIER 01CLINIMIX INJ 4.25/D20 BRAND TIER 03CLINIMIX INJ 4.25/D20 GENERIC TIER 01CLINIMIX INJ 4.25/D25 BRAND TIER 03CLINIMIX INJ 4.25/D25 GENERIC TIER 01CLINIMIX INJ 4.25/D5W BRAND TIER 03CLINIMIX INJ 5%/D15W BRAND TIER 03CLINIMIX INJ 5%/D20W BRAND TIER 03CLINIMIX INJ 5%/D25W BRAND TIER 03CLINIMIX E INJ 2.75/D10 BRAND TIER 03CLINIMIX E INJ 2.75/D5W BRAND TIER 03CLINIMIX E INJ 4.25/D10 BRAND TIER 03CLINIMIX E INJ 4.25/D25 BRAND TIER 03CLINIMIX E INJ 4.25/D25 GENERIC TIER 01CLINIMIX E INJ 4.25/D5W BRAND TIER 03CLINIMIX E INJ 5%/D15W BRAND TIER 03CLINIMIX E INJ 5%/D20W BRAND TIER 03CLINIMIX E INJ 5%/D25W 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= DrugExclusion81