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 StatusANTICONVULSANTS, MISCELLANEOUS FELBATOL TAB 600MG Brand‐O TIER 03 PAGABAPENTIN CAP 100MG GENERIC TIER 01GABAPENTIN CAP 300MG GENERIC TIER 01GABAPENTIN CAP 400MG GENERIC TIER 01GABAPENTIN SOL 250/5ML GENERIC TIER 01GABAPENTIN TAB 600MG GENERIC TIER 01GABAPENTIN TAB 800MG GENERIC TIER 01GABITRIL TAB 12MG BRAND TIER 02GABITRIL TAB 16MG BRAND TIER 02GABITRIL TAB 2MG Brand‐O TIER 02 PAGABITRIL TAB 4MG Brand‐O TIER 02 PAHORIZANT TAB 600MG BRAND TIER 03 PA QLKEPPRA SOL 100MG/ML Brand‐O TIER 03 PAKEPPRA TAB 1000MG Brand‐O TIER 03 PAKEPPRA TAB 250MG Brand‐O TIER 03 PAKEPPRA TAB 500MG Brand‐O TIER 03 PAKEPPRA TAB 750MG Brand‐O TIER 03 PAKEPPRA XR TAB 500MG Brand‐O TIER 03 PA QLKEPPRA XR TAB 750MG Brand‐O TIER 03 PA QLLAMICTAL CHW 25MG Brand‐O TIER 03 PALAMICTAL CHW 2MG BRAND TIER 03LAMICTAL CHW 5MG Brand‐O TIER 03 PALAMICTAL KIT START 35 BRAND TIER 02 PALAMICTAL KIT START 49 BRAND TIER 02 PALAMICTAL KIT START 98 BRAND TIER 02 PALAMICTAL TAB 100MG Brand‐O TIER 03 PA QLLAMICTAL TAB 150MG Brand‐O TIER 03 PA QLLAMICTAL TAB 200MG Brand‐O TIER 03 PA QLLAMICTAL TAB 25MG Brand‐O TIER 03 PA QLLAMICTAL ODT TAB 100MG BRAND TIER 02 PA QLLAMICTAL ODT TAB 200MG BRAND TIER 02 PA QLLAMICTAL ODT TAB 25MG BRAND TIER 02 PA QLLAMICTAL ODT TAB 50MG BRAND TIER 02 PA QLLAMICTAL XR TAB 100MG BRAND TIER 02 PA QLLAMICTAL XR TAB 200MG BRAND TIER 02 PA QLLAMICTAL XR TAB 250MG BRAND TIER 02 PALAMICTAL XR TAB 25MG BRAND TIER 02 PA QLLAMICTAL XR TAB 300MG BRAND TIER 02 PALAMICTAL XR TAB 50MG BRAND TIER 02 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= DrugExclusion26