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 StatusAMINOPENICILLINS AMOX/K CLAV CHW 400MG GENERIC TIER 01AMOX/K CLAV SUS 200/5ML GENERIC TIER 01AMOX/K CLAV SUS 250/5ML GENERIC TIER 01AMOX/K CLAV SUS 400/5ML GENERIC TIER 01AMOX/K CLAV SUS 600/5ML GENERIC TIER 01AMOX/K CLAV TAB 250MG GENERIC TIER 01AMOX/K CLAV TAB 500MG GENERIC TIER 01AMOX/K CLAV TAB 875MG GENERIC TIER 01AMOXICILLIN CAP 250MG GENERIC TIER 01AMOXICILLIN CAP 500MG GENERIC TIER 01AMOXICILLIN CHW 125MG GENERIC TIER 01AMOXICILLIN CHW 250MG GENERIC TIER 01AMOXICILLIN SUS 125/5ML GENERIC TIER 01AMOXICILLIN SUS 200/5ML GENERIC TIER 01AMOXICILLIN SUS 250/5ML GENERIC TIER 01AMOXICILLIN SUS 400/5ML GENERIC TIER 01AMOXICILLIN TAB 500MG GENERIC TIER 01AMOXICILLIN TAB 875MG GENERIC TIER 01AMOX‐POT CLA TAB ER GENERIC TIER 01AMPICILLIN CAP 250MG GENERIC TIER 01AMPICILLIN CAP 500MG GENERIC TIER 01AMPICILLIN INJ 10GM GENERIC TIER 01AMPICILLIN INJ 125MG GENERIC TIER 01AMPICILLIN INJ 1GM GENERIC TIER 01AMPICILLIN INJ 250MG GENERIC TIER 01AMPICILLIN INJ 2GM GENERIC TIER 01AMPICILLIN INJ 500MG GENERIC TIER 01AMPICILLIN SUS 125/5ML GENERIC TIER 01AMPICILLIN SUS 250/5ML GENERIC TIER 01AMP‐SULBACTA INJ 1.5GM GENERIC TIER 01AMP‐SULBACTA INJ 1‐0.5GM GENERIC TIER 01AMP‐SULBACTA INJ 10‐5GM GENERIC TIER 01AMP‐SULBACTA INJ 15GM GENERIC TIER 01AMP‐SULBACTA INJ 2‐1GM GENERIC TIER 01AMP‐SULBACTA INJ 3GM GENERIC TIER 01AUGMENTIN SUS 125/5ML BRAND TIER 02AUGMENTIN SUS 250/5ML Brand‐O TIER 03 PAAUGMENTIN TAB 500MG Brand‐O TIER 03 PAAUGMENTIN TAB 875MG Brand‐O TIER 03 PAKey: 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= DrugExclusion9