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 StatusDIRECT VASODILATORS FENOLDOPAM INJ 20MG/2ML GENERIC TIER 01HYDRALAZINE INJ 20MG/ML GENERIC TIER 01HYDRALAZINE TAB 100MG GENERIC TIER 01HYDRALAZINE TAB 10MG GENERIC TIER 01HYDRALAZINE TAB 25MG GENERIC TIER 01HYDRALAZINE TAB 50MG GENERIC TIER 01MINOXIDIL TAB 10MG GENERIC TIER 01MINOXIDIL TAB 2.5MG GENERIC TIER 01NITROPRESS INJ 25MG/ML BRAND TIER 03PROGLYCEM SUS 50MG/ML BRAND TIER 03DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS DANTRIUM CAP 100MG Brand‐O TIER 03 PADANTRIUM CAP 25MG Brand‐O TIER 03 PADANTRIUM CAP 50MG Brand‐O TIER 03 PADANTRIUM IV INJ 20MG Brand‐O TIER 03 PADANTROLENE CAP 100MG GENERIC TIER 01DANTROLENE CAP 25MG GENERIC TIER 01DANTROLENE CAP 50MG GENERIC TIER 01REVONTO INJ 20MG GENERIC TIER 01DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA INJ 200/10ML BRAND TIER 03 PA SPACTEMRA INJ 400/20ML BRAND TIER 03 PA SPACTEMRA INJ 80MG/4ML BRAND TIER 03 PA SPARAVA TAB 10MG Brand‐O TIER 03 PAARAVA TAB 20MG Brand‐O TIER 03 PACIMZIA KIT BRAND TIER 03 PA SPCIMZIA KIT 200MG/ML BRAND TIER 03 PA QL SPCIMZIA KIT STARTER BRAND TIER 03 PA SPENBREL INJ 25/0.5ML BRAND TIER 02 PA QL SPENBREL INJ 25MG BRAND TIER 02 PA QL SPENBREL INJ 50MG/ML BRAND TIER 02 PA QL SPENBREL SRCLK INJ 50MG/ML BRAND TIER 02 PA QL SPHUMIRA KIT 20MG/0.4 BRAND TIER 02 PA QL SPHUMIRA KIT 40MG/0.8 BRAND TIER 02 PA QL SPHUMIRA PEN KIT 40MG/0.8 BRAND TIER 02 PA QL SPHUMIRA PEN KIT CROHNS BRAND TIER 02 PA QL SPHUMIRA PEN KIT PSORIASI BRAND TIER 02 PA QL SPKINERET INJ BRAND TIER 03 PA QL SPLEFLUNOMIDE TAB 10MG GENERIC TIER 01LEFLUNOMIDE TAB 20MG 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= DrugExclusion135