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‐CONVERTING ENZYME INHIBITORS MAVIK TAB 4MG Brand‐O TIER 03 PAMOEXIPR/HCTZ TAB 15‐12.5 GENERIC TIER 01MOEXIPR/HCTZ TAB 15‐25MG GENERIC TIER 01MOEXIPR/HCTZ TAB 7.5‐12.5 GENERIC TIER 01MOEXIPRIL TAB 15MG GENERIC TIER 01MOEXIPRIL TAB 7.5MG GENERIC TIER 01PERINDOPRIL TAB 2MG GENERIC TIER 01PERINDOPRIL TAB 4MG GENERIC TIER 01PERINDOPRIL TAB 8MG GENERIC TIER 01PRINIVIL TAB 10MG Brand‐O TIER 03 PAPRINIVIL TAB 20MG Brand‐O TIER 03 PAPRINIVIL TAB 5MG Brand‐O TIER 03 PAPRINZIDE TAB 10‐12.5 Brand‐O TIER 03 PAPRINZIDE TAB 20‐12.5 Brand‐O TIER 03 PAQNAPRIL/HCTZ TAB 10‐12.5 GENERIC TIER 01QNAPRIL/HCTZ TAB 20‐12.5 GENERIC TIER 01QNAPRIL/HCTZ TAB 20‐25MG GENERIC TIER 01QUINAPRIL TAB 10MG GENERIC TIER 01QUINAPRIL TAB 20MG GENERIC TIER 01QUINAPRIL TAB 40MG GENERIC TIER 01QUINAPRIL TAB 5MG GENERIC TIER 01RAMIPRIL CAP 1.25MG GENERIC TIER 01RAMIPRIL CAP 10MG GENERIC TIER 01RAMIPRIL CAP 2.5MG GENERIC TIER 01RAMIPRIL CAP 5MG GENERIC TIER 01TRANDOLAPRIL TAB 1MG GENERIC TIER 01TRANDOLAPRIL TAB 2MG GENERIC TIER 01TRANDOLAPRIL TAB 4MG GENERIC TIER 01UNIRETIC TAB 15‐12.5 Brand‐O TIER 03 PAUNIRETIC TAB 15‐25MG Brand‐O TIER 03 PAUNIRETIC TAB 7.5‐12.5 Brand‐O TIER 03 PAUNIVASC TAB 15MG Brand‐O TIER 03 PAUNIVASC TAB 7.5MG Brand‐O TIER 03 PAVASERETIC TAB 10‐25MG Brand‐O TIER 03 PAVASOTEC TAB 10MG Brand‐O TIER 03 PAVASOTEC TAB 2.5MG Brand‐O TIER 03 PAVASOTEC TAB 20MG Brand‐O TIER 03 PAVASOTEC TAB 5MG Brand‐O TIER 03 PAZESTORETIC TAB 10‐12.5 Brand‐O TIER 03 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= DrugExclusion17