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 StatusDIHYDROPYRIDINES NIFEDIPINE CAP 20MG GENERIC TIER 01NIFEDIPINE TAB 30MG ER GENERIC TIER 01NIFEDIPINE TAB 60MG ER GENERIC TIER 01NIFEDIPINE TAB 90MG ER GENERIC TIER 01NIMODIPINE CAP 30MG GENERIC TIER 01NIMOTOP CAP 30MG Brand‐O TIER 03 PANISOLDIPINE TAB 17MG ER GENERIC TIER 01NISOLDIPINE TAB 20MG GENERIC TIER 01NISOLDIPINE TAB 25.5MG GENERIC TIER 01NISOLDIPINE TAB 30MG GENERIC TIER 01NISOLDIPINE TAB 34MG ER GENERIC TIER 01NISOLDIPINE TAB 40MG GENERIC TIER 01NISOLDIPINE TAB 8.5MG ER GENERIC TIER 01NORVASC TAB 10MG Brand‐O TIER 03 PANORVASC TAB 2.5MG Brand‐O TIER 03 PANORVASC TAB 5MG Brand‐O TIER 03 PAPROCARDIA CAP 10MG Brand‐O TIER 03 PAPROCARDIA XL TAB 30MG CR Brand‐O TIER 03 PAPROCARDIA XL TAB 60MG CR Brand‐O TIER 03 PAPROCARDIA XL TAB 90MG CR Brand‐O TIER 03 PASULAR TAB 17MG Brand‐O TIER 03 PASULAR TAB 25.5MG Brand‐O TIER 03 PASULAR TAB 34MG Brand‐O TIER 03 PASULAR TAB 8.5MG Brand‐O TIER 03 PATRIBENZOR20‐ TAB 5‐12.5MG BRAND TIER 02 PATRIBENZOR40‐ TAB 10‐12.5 BRAND TIER 02 PATRIBENZOR40‐ TAB 10‐25MG BRAND TIER 02 PATRIBENZOR40‐ TAB 5‐12.5MG BRAND TIER 02 PATRIBENZOR40‐ TAB 5‐25MG BRAND TIER 02 PATWYNSTA TAB 40‐10MG BRAND TIER 02 PATWYNSTA TAB 40‐5MG BRAND TIER 02 PATWYNSTA TAB 80‐10MG BRAND TIER 02 PATWYNSTA TAB 80‐5MG BRAND TIER 02 PACARDENE I.V. INJ 2.5MG/ML Brand‐O TIER 99 PA DEDIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS JANUMET TAB 50‐1000 BRAND TIER 02 PAJANUMET TAB 50‐500MG BRAND TIER 02 PAJANUMET XR TAB 100‐1000 BRAND TIER 02 PAJANUMET XR TAB 50‐1000 BRAND TIER 02 PAJANUMET XR TAB 50‐500MG BRAND TIER 02 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= DrugExclusion133