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 StatusCLASS IV ANTIARRHYTHMICS ADENOCARD INJ 12MG/4ML Brand‐O TIER 03 PAADENOCARD INJ 3MG/ML Brand‐O TIER 03 PAADENOCARD INJ 6MG/2ML Brand‐O TIER 03 PAADENOSINE INJ 12MG/4ML GENERIC TIER 01ADENOSINE INJ 3MG/ML GENERIC TIER 01ADENOSINE INJ 6MG/2ML GENERIC TIER 01COMPLEMENT INHIBITORS BERINERT INJ 500UNIT BRAND TIER 03 PA SPCINRYZE SOL 500 UNIT BRAND TIER 03 PA SPFIRAZYR INJ 30MG/3ML BRAND TIER 03 PA SPKALBITOR INJ 10MG/ML BRAND TIER 03 PASOLIRIS INJ 10MG/ML BRAND TIER 02 SPCONTRACEPTIVES ALTAVERA TAB GENERIC TIER 01ALYACEN TAB 1/35 GENERIC TIER 01ALYACEN TAB 7/7/7 GENERIC TIER 01AMETHIA TAB GENERIC TIER 01AMETHIA LO TAB GENERIC TIER 01AMETHYST TAB 90‐20MCG GENERIC TIER 01APRI TAB GENERIC TIER 01ARANELLE TAB GENERIC TIER 01AVIANE TAB GENERIC TIER 01AZURETTE TAB 28 DAY GENERIC TIER 01BALZIVA TAB GENERIC TIER 01BEYAZ TAB BRAND TIER 02BREVICON TAB 0.5/35 Brand‐O TIER 03 PABRIELLYN TAB GENERIC TIER 01CAMILA TAB 0.35MG GENERIC TIER 01CAMRESE TAB GENERIC TIER 01CAMRESE LO TAB GENERIC TIER 01CAZIANT PAK GENERIC TIER 01CESIA PAK GENERIC TIER 01CRYSELLE‐28 TAB 28 TABS GENERIC TIER 01CYCLAFEM TAB 1/35 GENERIC TIER 01CYCLAFEM TAB 7/7/7 GENERIC TIER 01CYCLESSA PAK Brand‐O TIER 03 PADASETTA TAB 1/35 GENERIC TIER 01DASETTA TAB 7/7/7 GENERIC TIER 01DESOGEN‐28 TAB Brand‐O TIER 03 PAELINEST TAB GENERIC TIER 01ELLA TAB 30MG BRAND TIER 02Key: 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= DrugExclusion93