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

More documents

Recommendations

Info

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE SEROTONIN AGONISTS MAXALT‐MLT TAB 5MG BRAND TIER 02 QLNARATRIPTAN TAB 1MG GENERIC TIER 01 QLNARATRIPTAN TAB 2.5MG GENERIC TIER 01 QLRELPAX TAB 20MG BRAND TIER 02 PA QLRELPAX TAB 40MG BRAND TIER 02 PA QLSUMATRIPTAN INJ 4MG/0.5 GENERIC TIER 01 PA QLSUMATRIPTAN INJ 6MG/0.5 GENERIC TIER 01 PA QLSUMATRIPTAN SPR 20MG/ACT GENERIC TIER 01 PA QLSUMATRIPTAN SPR 5MG/ACT GENERIC TIER 01 PA QLSUMATRIPTAN TAB 100MG GENERIC TIER 01 QLSUMATRIPTAN TAB 25MG GENERIC TIER 01 QLSUMATRIPTAN TAB 50MG GENERIC TIER 01 QLSUMAVEL DOSE INJ 6MG/0.5 BRAND TIER 03 PATREXIMET TAB 85‐500MG BRAND TIER 02 PA QLZOMIG SPR 5MG BRAND TIER 02 PAZOMIG TAB 2.5MG BRAND TIER 02 PA QLZOMIG TAB 5MG BRAND TIER 02 PA QLZOMIG ZMT TAB 2.5 MG BRAND TIER 02 QLZOMIG ZMT TAB 5MG BRAND TIER 02 QLSELECTIVE‐SEROTONIN REUPTAKE INHIBITORS CELEXA TAB 10MG Brand‐O TIER 03 PA QLCELEXA TAB 20MG Brand‐O TIER 03 PA QLCELEXA TAB 40MG Brand‐O TIER 03 PA QLCITALOPRAM SOL 10MG/5ML GENERIC TIER 01CITALOPRAM TAB 10MG GENERIC TIER 01 QLCITALOPRAM TAB 20MG GENERIC TIER 01 QLCITALOPRAM TAB 40MG GENERIC TIER 01 QLESCITALOPRAM SOL 5MG/5ML GENERIC TIER 01 PAESCITALOPRAM TAB 10MG GENERIC TIER 01 PA QLESCITALOPRAM TAB 20MG GENERIC TIER 01 PA QLESCITALOPRAM TAB 5MG GENERIC TIER 01 PA QLFLUOXETINE CAP 10MG GENERIC TIER 01FLUOXETINE CAP 10MG QLFLUOXETINE CAP 20MG GENERIC TIER 01FLUOXETINE CAP 20MG QLFLUOXETINE CAP 40MG GENERIC TIER 01 QLFLUOXETINE CAP 90MG DR GENERIC TIER 01 PA QLFLUOXETINE SOL 20MG/5ML GENERIC TIER 01FLUOXETINE TAB 10MG GENERIC TIER 01 QLFLUOXETINE TAB 20MG 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= DrugExclusion250
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusSELECTIVE‐SEROTONIN REUPTAKE INHIBITORS FLUOXETINE TAB 60MG GENERIC TIER 01FLUVOXAMINE TAB 100MG GENERIC TIER 01 QLFLUVOXAMINE TAB 25MG GENERIC TIER 01 QLFLUVOXAMINE TAB 50MG GENERIC TIER 01 QLGABOXETINE PAK BRAND TIER 03LEXAPRO SOL 5MG/5ML Brand‐O TIER 03 PALEXAPRO TAB 10MG Brand‐O TIER 03 PA QLLEXAPRO TAB 20MG Brand‐O TIER 03 PA QLLEXAPRO TAB 5MG Brand‐O TIER 03 PA QLLUVOX CR CAP 100MG BRAND TIER 03 PA QLLUVOX CR CAP 150MG BRAND TIER 03 PA QLOLANZA/FLUOX CAP 12‐25MG GENERIC TIER 01 QLOLANZA/FLUOX CAP 12‐50MG GENERIC TIER 01 QLOLANZA/FLUOX CAP 6‐25MG GENERIC TIER 01 QLOLANZA/FLUOX CAP 6‐50MG GENERIC TIER 01 QLPAROXETIN ER TAB 12.5MG GENERIC TIER 01 QLPAROXETIN ER TAB 37.5MG GENERIC TIER 01 QLPAROXETINE SUS 10MG/5ML GENERIC TIER 01PAROXETINE TAB 10MG GENERIC TIER 01 QLPAROXETINE TAB 20MG GENERIC TIER 01 QLPAROXETINE TAB 25MG ER GENERIC TIER 01 QLPAROXETINE TAB 30MG GENERIC TIER 01 QLPAROXETINE TAB 40MG GENERIC TIER 01 QLPAXIL SUS 10MG/5ML Brand‐O TIER 02 PAPAXIL TAB 10MG Brand‐O TIER 03 PA QLPAXIL TAB 30MG Brand‐O TIER 03 PA QLPAXIL TAB 40MG Brand‐O TIER 03 PA QLPAXIL CR TAB 12.5MG Brand‐O TIER 03 PA QLPAXIL CR TAB 25MG Brand‐O TIER 03 PA QLPAXIL CR TAB 37.5MG Brand‐O TIER 03 PA QLPEXEVA TAB 10MG BRAND TIER 03 PA QLPEXEVA TAB 20MG BRAND TIER 03 PA QLPEXEVA TAB 30MG BRAND TIER 03 PA QLPEXEVA TAB 40MG BRAND TIER 03 PA QLPROZAC CAP 10MG Brand‐O TIER 03 PA QLPROZAC CAP 20MG Brand‐O TIER 03 PA QLPROZAC CAP 40MG Brand‐O TIER 03 PA QLPROZAC WEEKL CAP 90MG Brand‐O TIER 03 PA QLSARAFEM TAB 10MG BRAND TIER 03 PA 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= DrugExclusion251
Page 1 and 2:
BMC HealthNet Plan Drug List - Comm
Page 3 and 4:
AHFS Therapeutic Class Description
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201: AHFS Therapeutic Class Description
Page 280: AHFS Therapeutic Class Description
show all

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

Create successful ePaper yourself

Delete template?

Save as template?