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 StatusANTICOAGULANTS, MISCELLANEOUS TRICITRASOL CON BRAND TIER 03ANTICONVULSANTS, MISCELLANEOUS BANZEL SUS 40MG/ML BRAND TIER 03 QLBANZEL TAB 200MG BRAND TIER 02 QLBANZEL TAB 400MG BRAND TIER 02 QLCARBAMAZEPIN CAP 100MG ER GENERIC TIER 01CARBAMAZEPIN CAP 200MG ER GENERIC TIER 01CARBAMAZEPIN CAP 300MG ER GENERIC TIER 01CARBAMAZEPIN CHW 100MG GENERIC TIER 01CARBAMAZEPIN SUS 100/5ML GENERIC TIER 01CARBAMAZEPIN TAB 200MG GENERIC TIER 01CARBAMAZEPIN TAB 200MG ER GENERIC TIER 01CARBAMAZEPIN TAB 400MG ER GENERIC TIER 01CARBATROL CAP 100MG Brand‐O TIER 03 PACARBATROL CAP 200MG Brand‐O TIER 03 PACARBATROL CAP 300MG Brand‐O TIER 03 PADEPACON INJ 100MG/ML Brand‐O TIER 03 PADEPAKENE CAP 250MG Brand‐O TIER 03 PADEPAKENE SYP 250/5ML Brand‐O TIER 03 PADEPAKOTE TAB 125MG DR Brand‐O TIER 03 PADEPAKOTE TAB 250MG DR Brand‐O TIER 03 PADEPAKOTE TAB 500MG DR Brand‐O TIER 03 PADEPAKOTE ER TAB 250MG Brand‐O TIER 03 PADEPAKOTE ER TAB 500MG Brand‐O TIER 03 PADEPAKOTE SPR CAP 125MG Brand‐O TIER 03 PADIVALPROEX CAP 125MG GENERIC TIER 01DIVALPROEX TAB 125MG DR GENERIC TIER 01DIVALPROEX TAB 250MG DR GENERIC TIER 01DIVALPROEX TAB 250MG ER GENERIC TIER 01DIVALPROEX TAB 500MG DR GENERIC TIER 01DIVALPROEX TAB 500MG ER GENERIC TIER 01EPITOL TAB 200MG GENERIC TIER 01EQUETRO CAP 100MG BRAND TIER 03EQUETRO CAP 200MG BRAND TIER 03EQUETRO CAP 300MG BRAND TIER 03FELBAMATE SUS 600/5ML GENERIC TIER 01FELBAMATE TAB 400MG GENERIC TIER 01FELBAMATE TAB 600MG GENERIC TIER 01FELBATOL SUS 600/5ML Brand‐O TIER 03 PAFELBATOL TAB 400MG 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= DrugExclusion25