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 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