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 StatusNITRATES AND NITRITES NITROGLY/D5W INJ 50MG GENERIC TIER 01NITROGLYCER CAP 2.5MG ER GENERIC TIER 99 DENITROGLYCER CAP 6.5MG ER GENERIC TIER 99 DENITROGLYCER CAP 9MG ER GENERIC TIER 99 DENITROGLYCER DIS 0.1MG/HR GENERIC TIER 01NITROGLYCER DIS 0.2MG/HR GENERIC TIER 01NITROGLYCER DIS 0.4MG/HR GENERIC TIER 01NITROGLYCER DIS 0.6MG/HR GENERIC TIER 01NITROGLYCER INJ 5MG/ML GENERIC TIER 01NITROGLYCERI DIS 0.6MG/HR GENERIC TIER 01NITROGLYCRN SPR LINGUAL GENERIC TIER 01NITROLINGUAL SPR PUMPSPRA BRAND TIER 02NITROMIST AER 400MCG BRAND TIER 03NITROSTAT SUB 0.3MG BRAND TIER 02NITROSTAT SUB 0.4MG BRAND TIER 02NITROSTAT SUB 0.6MG BRAND TIER 02NITRO‐TIME CAP 2.5MG CR GENERIC TIER 99 DENITRO‐TIME CAP 6.5MG CR GENERIC TIER 99 DENITRO‐TIME CAP 9MG CR GENERIC TIER 99 DENONERGOT‐DERIV.DOPAMINE RECEPTOR AGONIST APOKYN INJ BRAND TIER 02APOKYN INJ 10MG/ML BRAND TIER 02MIRAPEX TAB 0.125MG Brand‐O TIER 03 PAMIRAPEX TAB 0.25MG Brand‐O TIER 03 PAMIRAPEX TAB 0.5MG Brand‐O TIER 03 PAMIRAPEX TAB 0.75MG Brand‐O TIER 03 PAMIRAPEX TAB 1.5MG Brand‐O TIER 03 PAMIRAPEX TAB 1MG Brand‐O TIER 03 PAMIRAPEX ER TAB 0.375MG BRAND TIER 02 PA QLMIRAPEX ER TAB 0.75MG BRAND TIER 02 PA QLMIRAPEX ER TAB 1.5MG BRAND TIER 02 PA QLMIRAPEX ER TAB 2.25MG BRAND TIER 02 PA QLMIRAPEX ER TAB 3.75MG BRAND TIER 02 PA QLMIRAPEX ER TAB 3MG BRAND TIER 02 PA QLMIRAPEX ER TAB 4.5MG BRAND TIER 02 PA QLNEUPRO DIS 1MG/24HR BRAND TIER 03NEUPRO DIS 2MG/24HR BRAND TIER 03NEUPRO DIS 3MG/24HR BRAND TIER 03NEUPRO DIS 4MG/24HR BRAND TIER 03Key: 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= DrugExclusion191