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 CLINISOL SF INJ 15% GENERIC TIER 01CYSTEINE HCL INJ 50MG/ML GENERIC TIER 01DEXTROSE INJ 10% GENERIC TIER 01 SPDEXTROSE INJ 2.5% GENERIC TIER 01 SPDEXTROSE INJ 20% GENERIC TIER 01 SPDEXTROSE INJ 25% GENERIC TIER 01 SPDEXTROSE INJ 30% GENERIC TIER 01 SPDEXTROSE INJ 40% GENERIC TIER 01 SPDEXTROSE INJ 5% GENERIC TIER 01 SPDEXTROSE INJ 5% PGBK GENERIC TIER 01 SPDEXTROSE INJ 50% GENERIC TIER 01 SPDEXTROSE INJ 70% GENERIC TIER 01 SPENLYTE CAP BRAND TIER 99 DEFOVEX CAP BRAND TIER 99 DEFREAMINE HBC INJ 6.9% BRAND TIER 03FREAMINE III INJ 10% BRAND TIER 03FREAMINE III INJ 3% BRAND TIER 03FREAMINE III INJ 8.5% GENERIC TIER 01FRUCTOSE GRA GENERIC TIER 99 DEGABADONE CAP BRAND TIER 99 DEGLUTATHIONE CRY REDUCED GENERIC TIER 99 DEGLUTATHIONE POW GENERIC TIER 99 DEGLUTATHIONE POW REDUCED GENERIC TIER 99 DEHEPATAMINE SOL 8% GENERIC TIER 01HEPATASOL INJ 8% GENERIC TIER 01HYPERTENSA CAP BRAND TIER 99 DEINTRALIPID INJ 20% GENERIC TIER 01INTRALIPID INJ 30% Brand‐O TIER 03 PAL‐CYSTEINE INJ 50MG/ML GENERIC TIER 01L‐GLUTAMINE CRY FCC GENERIC TIER 99 DELIPOSYN II INJ 10% Brand‐O TIER 03 PALIPOSYN II INJ 20% Brand‐O TIER 03 PALIPOSYN III INJ 10% Brand‐O TIER 03 PALIPOSYN III INJ 20% Brand‐O TIER 03 PALIPOSYN III INJ 30% GENERIC TIER 01LISTER‐V CAP BRAND TIER 99 DEL‐THREONINE CRY GENERIC TIER 99 DELUKAID GLA EMU 1GM/ML BRAND TIER 99 DELUNGLAID EMU 1GM/ML BRAND 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= DrugExclusion82