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 StatusTRYCYCLICS & OTHER NOREPINEPH.‐RU INHIB NORTRIPTYLIN CAP 25MG GENERIC TIER 01NORTRIPTYLIN CAP 50MG GENERIC TIER 01NORTRIPTYLIN CAP 75MG GENERIC TIER 01NORTRIPTYLIN SOL 10MG/5ML GENERIC TIER 01PAMELOR CAP 10MG Brand‐O TIER 03 PAPAMELOR CAP 25MG Brand‐O TIER 03 PAPAMELOR CAP 50MG Brand‐O TIER 03 PAPAMELOR CAP 75MG Brand‐O TIER 03 PAPERPHEN/AMIT TAB 2‐10MG GENERIC TIER 01PERPHEN/AMIT TAB 2‐25MG GENERIC TIER 01PERPHEN/AMIT TAB 4‐10MG GENERIC TIER 01PERPHEN/AMIT TAB 4‐25MG GENERIC TIER 01PERPHEN/AMIT TAB 4‐50MG GENERIC TIER 01PROTRIPTYLIN TAB 10MG GENERIC TIER 01PROTRIPTYLIN TAB 5MG GENERIC TIER 01SENTRAVIL PM PAK ‐25 BRAND TIER 03SILENOR TAB 3MG BRAND TIER 02 PA QLSILENOR TAB 6MG BRAND TIER 02 PA QLSURMONTIL CAP 100MG Brand‐O TIER 03 PASURMONTIL CAP 25MG Brand‐O TIER 03 PASURMONTIL CAP 50MG Brand‐O TIER 03 PATOFRANIL TAB 10MG Brand‐O TIER 03 PATOFRANIL TAB 25MG Brand‐O TIER 03 PATOFRANIL TAB 50MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 100MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 125MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 150MG Brand‐O TIER 03 PATOFRANIL‐PM CAP 75MG Brand‐O TIER 03 PATRIMIPRAMINE CAP 100MG GENERIC TIER 01TRIMIPRAMINE CAP 25MG GENERIC TIER 01TRIMIPRAMINE CAP 50MG GENERIC TIER 01VIVACTIL TAB 10MG Brand‐O TIER 03 PAVIVACTIL TAB 5MG Brand‐O TIER 03 PATUBERCULOSIS APLISOL INJ 5/0.1ML BRAND TIER 03TUBERSOL INJ 5/0.1ML BRAND TIER 03URICOSURIC AGENTS PROBEN/COLCH TAB 500‐0.5 GENERIC TIER 01PROBENECID TAB 500MG GENERIC TIER 01URINARY ANTI‐INFECTIVES FURADANTIN SUS 25MG/5ML Brand‐O TIER 03 PAHIPREX TAB 1GM 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= DrugExclusion273