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 VALPROIC ACD CAP 250MG GENERIC TIER 01VALPROIC ACD SOL 250/5ML GENERIC TIER 01VALPROIC ACD SYP 250/5ML GENERIC TIER 01VIMPAT INJ 200MG/20 BRAND TIER 03 PAVIMPAT SOL 10MG/ML BRAND TIER 02 PA QLVIMPAT TAB 100MG BRAND TIER 02 PA QLVIMPAT TAB 150MG BRAND TIER 02 PA QLVIMPAT TAB 200MG BRAND TIER 02 PA QLVIMPAT TAB 50MG BRAND TIER 02 PA QLZONEGRAN CAP 100MG Brand‐O TIER 03 PAZONEGRAN CAP 25MG Brand‐O TIER 03 PAZONISAMIDE CAP 100MG GENERIC TIER 01ZONISAMIDE CAP 25MG GENERIC TIER 01ZONISAMIDE CAP 50MG GENERIC TIER 01TIAGABINE TAB 2MG GENERIC TIER 01TIAGABINE TAB 4MG GENERIC TIER 01KEPPRA INJ 500/5ML Brand‐O TIER 99 PA DELEVETIRACETM INJ 500/5ML GENERIC TIER 99 DEANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG BRAND TIER 03 PA QLAPLENZIN TAB 348MG BRAND TIER 03 PA QLAPLENZIN TAB 522MG BRAND TIER 03 PA QLAPPBUTAMONE PAK BRAND TIER 03APPBUTAMONE PAK ‐D BRAND TIER 03BUDEPRION TAB 100MG SR GENERIC TIER 01 QLBUDEPRION TAB 150MG SR GENERIC TIER 01 QLBUDEPRION XL TAB 150MG GENERIC TIER 01 QLBUDEPRION XL TAB 300MG GENERIC TIER 01 QLBUPROBAN TAB 150MG GENERIC TIER 01BUPROPION TAB 100MG GENERIC TIER 01 QLBUPROPION TAB 100MG ER GENERIC TIER 01 QLBUPROPION TAB 100MG SR GENERIC TIER 01 QLBUPROPION TAB 150MG GENERIC TIER 01BUPROPION TAB 150MG ER GENERIC TIER 01 QLBUPROPION TAB 150MG SR GENERIC TIER 01 QLBUPROPION TAB 200MG ER GENERIC TIER 01 QLBUPROPION TAB 200MG SR GENERIC TIER 01 QLBUPROPION TAB 75MG GENERIC TIER 01 QLBUPROPN HCL TAB 150MG XL GENERIC TIER 01 QLBUPROPN HCL TAB 300MG XL 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= DrugExclusion29