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 StatusDIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS JANUVIA TAB 100MG BRAND TIER 02 PAJANUVIA TAB 25MG BRAND TIER 02 PAJANUVIA TAB 50MG BRAND TIER 02 PAJENTADUETO TAB 2.5‐1000 BRAND TIER 03 PAJENTADUETO TAB 2.5‐500 BRAND TIER 03 PAJENTADUETO TAB 2.5‐850 BRAND TIER 03 PAJUVISYNC TAB 100‐10MG BRAND TIER 03 PAJUVISYNC TAB 100‐20MG BRAND TIER 03 PAJUVISYNC TAB 100‐40MG BRAND TIER 03 PAKOMBIGLYZE TAB 2.5‐1000 BRAND TIER 02 PAKOMBIGLYZE TAB 5‐1000MG BRAND TIER 02 PAKOMBIGLYZE TAB 5‐500MG BRAND TIER 02 PAONGLYZA TAB 2.5MG BRAND TIER 02 PAONGLYZA TAB 5MG BRAND TIER 02 PATRADJENTA TAB 5MG BRAND TIER 02 PAJUVISYNC TAB 50‐10MG BRAND TIER 03JUVISYNC TAB 50‐20MG BRAND TIER 03JUVISYNC TAB 50‐40MG BRAND TIER 03DIRECT FACTOR XA INHIBITORS ARIXTRA SOL 10/0.8 Brand‐O TIER 03 PAARIXTRA SOL 2.5/0.5 Brand‐O TIER 03 PAARIXTRA SOL 5.0/0.4 Brand‐O TIER 03 PAARIXTRA SOL 7.5/0.6 Brand‐O TIER 03 PAFONDAPARINUX SOL 10/0.8 GENERIC TIER 01FONDAPARINUX SOL 2.5/0.5 GENERIC TIER 01FONDAPARINUX SOL 5.0/0.4 GENERIC TIER 01FONDAPARINUX SOL 7.5/0.6 GENERIC TIER 01XARELTO TAB 10MG BRAND TIER 03 PA QLXARELTO TAB 15MG BRAND TIER 03 PA QLXARELTO TAB 20MG BRAND TIER 03 PA QLDIRECT THROMBIN INHIBITORS ANGIOMAX INJ 250MG BRAND TIER 03ARGATROBAN INJ 100MG/ML GENERIC TIER 01ARGATROBAN INJ 125/125 GENERIC TIER 01ARGATROBAN INJ 50MG/50M GENERIC TIER 01IPRIVASK INJ 15MG BRAND TIER 03 PAPRADAXA CAP 150MG BRAND TIER 02 PA QLPRADAXA CAP 75MG BRAND TIER 02 PA QLREFLUDAN INJ 50MG BRAND TIER 03DIRECT VASODILATORS CORLOPAM INJ 10MG/ML Brand‐O TIER 03 PAFENOLDOPAM INJ 10MG/ML 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= DrugExclusion134