BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNONERGOT‐DERIV.DOPAMINE RECEPTOR AGONIST NEUPRO DIS 6MG/24HR BRAND TIER 03NEUPRO DIS 8MG/24HR BRAND TIER 03PRAMIPEXOLE TAB 0.125MG GENERIC TIER 01PRAMIPEXOLE TAB 0.25MG GENERIC TIER 01PRAMIPEXOLE TAB 0.5MG GENERIC TIER 01PRAMIPEXOLE TAB 0.75MG GENERIC TIER 01PRAMIPEXOLE TAB 1.5MG GENERIC TIER 01PRAMIPEXOLE TAB 1MG GENERIC TIER 01REQUIP TAB 0.25MG Brand‐O TIER 03 PAREQUIP TAB 0.5MG Brand‐O TIER 03 PAREQUIP TAB 1MG Brand‐O TIER 03 PAREQUIP TAB 2MG Brand‐O TIER 03 PAREQUIP TAB 3MG Brand‐O TIER 03 PAREQUIP TAB 4MG Brand‐O TIER 03 PAREQUIP TAB 5MG Brand‐O TIER 03 PAREQUIP XL TAB 12MG Brand‐O TIER 03 PA QLREQUIP XL TAB 2MG Brand‐O TIER 03 PA QLREQUIP XL TAB 4MG Brand‐O TIER 03 PA QLREQUIP XL TAB 6MG Brand‐O TIER 03 PA QLREQUIP XL TAB 8MG Brand‐O TIER 03 PA QLROPINIROLE TAB 0.25MG GENERIC TIER 01ROPINIROLE TAB 0.5MG GENERIC TIER 01ROPINIROLE TAB 12MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 1MG GENERIC TIER 01ROPINIROLE TAB 2MG GENERIC TIER 01ROPINIROLE TAB 2MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 3MG GENERIC TIER 01ROPINIROLE TAB 4MG GENERIC TIER 01ROPINIROLE TAB 4MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 5MG GENERIC TIER 01ROPINIROLE TAB 6MG ER GENERIC TIER 01 PA QLROPINIROLE TAB 8MG ER GENERIC TIER 01 PA QLNONNUCLEOSIDE REV.TRANSCRIPTASE INHIB. COMPLERA TAB BRAND TIER 02EDURANT TAB 25MG BRAND TIER 02INTELENCE TAB 100MG BRAND TIER 02INTELENCE TAB 200MG BRAND TIER 02INTELENCE TAB 25MG BRAND TIER 02NEVIRAPINE SUS 50MG/5ML GENERIC TIER 01NEVIRAPINE TAB 200MG 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= DrugExclusion192
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusNONNUCLEOSIDE REV.TRANSCRIPTASE INHIB. RESCRIPTOR TAB 100 MG BRAND TIER 02RESCRIPTOR TAB 200MG BRAND TIER 02SUSTIVA CAP 200MG BRAND TIER 02SUSTIVA CAP 50MG BRAND TIER 02SUSTIVA TAB 600MG BRAND TIER 02VIRAMUNE SUS 50MG/5ML BRAND TIER 03VIRAMUNE TAB 200MG Brand‐O TIER 03 PAVIRAMUNE XR TAB BRAND TIER 03NON‐SEL.ALPHA‐ADRENERGIC BLOCKING AGENTS D.H.E. 45 INJ 1MG/ML Brand‐O TIER 03 PADIBENZYLINE CAP 10MG BRAND TIER 02DIHYDROERGOT CRY MESYLATE GENERIC TIER 99 DEDIHYDROERGOT INJ 1MG/ML GENERIC TIER 01ERGOLOID MES TAB 1MG ORAL GENERIC TIER 01ERGOMAR SUB 2MG BRAND TIER 02MIGRANAL SPR 4MG/ML BRAND TIER 03 QLPHENTOL MESY INJ 5MG GENERIC TIER 01PHENTOLAMINE INJ MESYLATE GENERIC TIER 01NON‐SELECTIVE BETA‐ADRENERGIC AGONISTS ISUPREL INJ 0.2MG/ML BRAND TIER 03NUCLEOSIDE,NUCLEOTIDE REV.TRNSCRIP.INHIB ABACAVIR TAB 300MG GENERIC TIER 01COMBIVIR TAB 150‐300 Brand‐O TIER 03 PADIDANOSINE CAP 125MG GENERIC TIER 01DIDANOSINE CAP 200MG GENERIC TIER 01DIDANOSINE CAP 250MG GENERIC TIER 01DIDANOSINE CAP 400MG GENERIC TIER 01EMTRIVA CAP 200MG BRAND TIER 02EMTRIVA SOL 10MG/ML BRAND TIER 02EPIVIR SOL 10MG/ML BRAND TIER 02EPIVIR TAB 150MG Brand‐O TIER 03 PAEPIVIR TAB 300MG Brand‐O TIER 03 PAEPIVIR HBV SOL 5MG/ML BRAND TIER 02EPIVIR HBV TAB 100MG BRAND TIER 02EPZICOM TAB BRAND TIER 02LAMIVUD/ZIDO TAB 150‐300 GENERIC TIER 01LAMIVUDINE TAB 150MG GENERIC TIER 01LAMIVUDINE TAB 300MG GENERIC TIER 01RETROVIR CAP 100MG Brand‐O TIER 03 PARETROVIR INJ 10MG/ML BRAND TIER 03RETROVIR SYP 50MG/5ML 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= DrugExclusion193
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BMC HealthNet Plan Drug List - Comm
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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