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 StatusSELECTIVE ALPHA‐1‐ADRENERGIC BLOCK.AGENT RAPAFLO CAP 4MG BRAND TIER 02 PA QLRAPAFLO CAP 8MG BRAND TIER 02 PA QLTAMSULOSIN CAP 0.4MG GENERIC TIER 01UROXATRAL TAB 10MG Brand‐O TIER 03 PA QLSELECTIVE BETA‐1‐ADRENERGIC AGONISTS DOBUTAM/D5W INJ 1MG/ML GENERIC TIER 01DOBUTAM/D5W INJ 2MG/ML GENERIC TIER 01DOBUTAM/D5W INJ 4MG/ML GENERIC TIER 01DOBUTAMINE INJ 250MG GENERIC TIER 01DOBUTAMINE INJ 500MG GENERIC TIER 01DOPAMINE INJ 160MG/ML GENERIC TIER 01DOPAMINE INJ 40MG/ML GENERIC TIER 01DOPAMINE INJ 80MG/ML GENERIC TIER 01DOPAMINE/D5W INJ 0.8MG/ML GENERIC TIER 01DOPAMINE/D5W INJ 1.6MG/ML GENERIC TIER 01 SPDOPAMINE/D5W INJ 3.2MG/ML GENERIC TIER 01SELECTIVE BETA‐2‐ADRENERGIC AGONISTS ACCUNEB NEB 0.63MG/3 Brand‐O TIER 03 PA QLACCUNEB NEB 1.25MG/3 Brand‐O TIER 03 PA QLADVAIR DISKU AER 100/50 BRAND TIER 03 PA QLADVAIR DISKU AER 250/50 BRAND TIER 03 PA QLADVAIR DISKU AER 500/50 BRAND TIER 03 PA QLADVAIR HFA AER 115/21 BRAND TIER 03 PA QLADVAIR HFA AER 230/21 BRAND TIER 03 PA QLADVAIR HFA AER 45/21 BRAND TIER 03 PA QLALBUTEROL NEB 0.083% GENERIC TIER 01 QLALBUTEROL NEB 0.5% GENERIC TIER 01 QLALBUTEROL NEB 0.63MG/3 GENERIC TIER 01 QLALBUTEROL NEB 1.25MG/3 GENERIC TIER 01 QLALBUTEROL SYP 2MG/5ML GENERIC TIER 01ALBUTEROL TAB 2MG GENERIC TIER 01ALBUTEROL TAB 4MG GENERIC TIER 01ALBUTEROL TAB 4MG ER GENERIC TIER 01ALBUTEROL TAB 8MG ER GENERIC TIER 01ARCAPTA CAP 75MCG BRAND TIER 03 PA QLBROVANA NEB 15MCG BRAND TIER 03COMBIVENT AER BRAND TIER 02 QLCOMBIVENT AER RESPIMAT BRAND TIER 02DUONEB SOL Brand‐O TIER 03 PA QLFORADIL CAP AEROLIZE BRAND TIER 02 QLIPRATROPIUM/ SOL ALBUTER GENERIC TIER 01 QLKey: 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= DrugExclusion248