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 StatusANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN/HCT TAB 50‐12.5 GENERIC TIER 01 PAMICARDIS TAB 20MG BRAND TIER 02 PAMICARDIS TAB 40MG BRAND TIER 02 PAMICARDIS TAB 80MG BRAND TIER 02 PAMICARDIS HCT TAB 40/12.5 BRAND TIER 02 PAMICARDIS HCT TAB 80/12.5 BRAND TIER 02 PAMICARDIS HCT TAB 80‐25MG BRAND TIER 02 PATEVETEN TAB 400MG BRAND TIER 03 PATEVETEN TAB 600MG Brand‐O TIER 03 PATEVETEN HCT TAB 600‐12.5 BRAND TIER 03 PATEVETEN HCT TAB 600‐25MG BRAND TIER 03 PAVALSART/HCTZ TAB 160‐12.5 GENERIC TIER 01 PAVALSART/HCTZ TAB 160‐25MG GENERIC TIER 01 PAVALSART/HCTZ TAB 320‐12.5 GENERIC TIER 01 PAVALSART/HCTZ TAB 320‐25MG GENERIC TIER 01 PAVALSART/HCTZ TAB 80‐12.5 GENERIC TIER 01 PAANGIOTENSIN‐CONVERTING ENZYME INHIBITORS ACCUPRIL TAB 10MG Brand‐O TIER 03 PAACCUPRIL TAB 20MG Brand‐O TIER 03 PAACCUPRIL TAB 40MG Brand‐O TIER 03 PAACCUPRIL TAB 5MG Brand‐O TIER 03 PAACCURETIC TAB 10‐12.5 Brand‐O TIER 03 PAACCURETIC TAB 20‐12.5 Brand‐O TIER 03 PAACCURETIC TAB 20‐25MG Brand‐O TIER 03 PAACEON TAB 2MG Brand‐O TIER 03 PAACEON TAB 4MG Brand‐O TIER 03 PAACEON TAB 8MG Brand‐O TIER 03 PAALTACE CAP 1.25MG Brand‐O TIER 03 PAALTACE CAP 10MG Brand‐O TIER 03 PAALTACE CAP 2.5MG Brand‐O TIER 03 PAALTACE CAP 5MG Brand‐O TIER 03 PABENAZEP/HCTZ TAB 10‐12.5 GENERIC TIER 01BENAZEP/HCTZ TAB 20‐12.5 GENERIC TIER 01BENAZEP/HCTZ TAB 20‐25MG GENERIC TIER 01BENAZEP/HCTZ TAB 5‐6.25 GENERIC TIER 01BENAZEPRIL TAB 10MG GENERIC TIER 01BENAZEPRIL TAB 20MG GENERIC TIER 01BENAZEPRIL TAB 40MG GENERIC TIER 01BENAZEPRIL TAB 5MG 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= DrugExclusion15