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 StatusCARBONIC ANHYDRASE INHIBITORS (EENT) ACETAZOLAMID INJ 500MG GENERIC TIER 01ACETAZOLAMID TAB 125MG GENERIC TIER 01ACETAZOLAMID TAB 250MG GENERIC TIER 01AZOPT SUS 1% OP BRAND TIER 02COSOPT SOL 2‐0.5%OP Brand‐O TIER 03 PACOSOPT PF SOL BRAND TIER 03DIAMOX SEQUE CAP 500MG CR Brand‐O TIER 03 PADORZOL/TIMOL SOL 2‐0.5%OP GENERIC TIER 01DORZOLAMIDE SOL 2% OP GENERIC TIER 01METHAZOLAMID TAB 25MG GENERIC TIER 01METHAZOLAMID TAB 50MG GENERIC TIER 01NEPTAZANE TAB 25MG Brand‐O TIER 03 PANEPTAZANE TAB 50MG Brand‐O TIER 03 PATRUSOPT SOL 2% OP Brand‐O TIER 03 PACARDIAC DRUGS, MISCELLANEOUS RANEXA TAB 1000MG BRAND TIER 02 PARANEXA TAB 500MG BRAND TIER 02 PACARDIAC FUNCTION ADENOSCAN INJ 3MG/ML BRAND TIER 03DEXTROSE INJ 5% BRAND TIER 03INDOCYANINE INJ 25MG GENERIC TIER 99 DELEXISCAN INJ 0.4MG BRAND TIER 03MYOVIEW KIT BRAND TIER 99 DESODIUM CHLOR INJ 0.9% BRAND TIER 03THALLOUS CL INJ TL 201 GENERIC TIER 99 DEIC GREEN INJ 25MG Brand‐O TIER 99 PA DECARDIOTONIC AGENTS DIGOXIN INJ 0.25MG/1 GENERIC TIER 01DIGOXIN SOL 50MCG/ML GENERIC TIER 01DIGOXIN TAB 0.125MG GENERIC TIER 01DIGOXIN TAB 0.25MG GENERIC TIER 01LANOXIN INJ 0.1MG/ML BRAND TIER 03LANOXIN INJ 0.25MG/1 Brand‐O TIER 03 PALANOXIN TAB 0.125MG Brand‐O TIER 03 PALANOXIN TAB 0.25MG Brand‐O TIER 03 PAMILRINONE INJ 1MG/ML GENERIC TIER 01MILRINONE INJ DW5 GENERIC TIER 01CARIOSTATIC AGENTS CAVAREST GEL 1.1% GENERIC TIER 01CAVIRINSE SOL 0.2% GENERIC TIER 01CLINPRO 5000 PST 1.1% GENERIC TIER 01CONTROLRX CRE 1.1% GENERIC TIER 01CONTROLRX PST 1.1% 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= DrugExclusion84