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 StatusSULFONAMIDES (SYSTEMIC) SULFAZINE TAB 500MG GENERIC TIER 01SULFAZINE EC TAB 500MG GENERIC TIER 01SULFISOXIZOL CRY GENERIC TIER 99 DESULFISOXIZOL CRY USP NF GENERIC TIER 99 DESULFONYLUREAS AMARYL TAB 1MG Brand‐O TIER 03 PAAMARYL TAB 2MG Brand‐O TIER 03 PAAMARYL TAB 4MG Brand‐O TIER 03 PACHLORPROPAM TAB 100MG GENERIC TIER 01CHLORPROPAM TAB 250MG GENERIC TIER 01DIABETA TAB 1.25MG BRAND TIER 03DIABETA TAB 2.5MG BRAND TIER 03DIABETA TAB 5MG BRAND TIER 03GLIMEPIRIDE TAB 1MG GENERIC TIER 01GLIMEPIRIDE TAB 2MG GENERIC TIER 01GLIMEPIRIDE TAB 4MG GENERIC TIER 01GLIP/METFORM TAB 2.5‐250M GENERIC TIER 01GLIP/METFORM TAB 2.5‐500M GENERIC TIER 01GLIP/METFORM TAB 5‐500MG GENERIC TIER 01GLIPIZIDE TAB 10MG GENERIC TIER 01GLIPIZIDE TAB 5MG GENERIC TIER 01GLIPIZIDE ER TAB 10MG GENERIC TIER 01GLIPIZIDE ER TAB 2.5MG GENERIC TIER 01GLIPIZIDE ER TAB 5MG GENERIC TIER 01GLIPIZIDE XL TAB 10MG GENERIC TIER 01GLIPIZIDE XL TAB 2.5MG GENERIC TIER 01GLIPIZIDE XL TAB 5MG GENERIC TIER 01GLUCOTROL TAB 10MG Brand‐O TIER 03 PAGLUCOTROL TAB 5MG Brand‐O TIER 03 PAGLUCOTROL XL TAB 10MG Brand‐O TIER 03 PAGLUCOTROL XL TAB 2.5MG Brand‐O TIER 03 PAGLUCOTROL XL TAB 5MG Brand‐O TIER 03 PAGLUCOVANCE TAB 1.25‐250 Brand‐O TIER 03 PAGLUCOVANCE TAB 2.5‐500 Brand‐O TIER 03 PAGLUCOVANCE TAB 5‐500MG Brand‐O TIER 03 PAGLYB/METFORM TAB 1.25‐250 GENERIC TIER 01GLYB/METFORM TAB 2.5‐500 GENERIC TIER 01GLYB/METFORM TAB 5‐500MG GENERIC TIER 01GLYBURID MCR TAB 1.5MG GENERIC TIER 01GLYBURID MCR TAB 3MG GENERIC TIER 01Key: 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= DrugExclusion262