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 StatusANTIPSYCHOTICS, MISCELLANEOUS LOXAPINE CAP 25MG GENERIC TIER 01LOXAPINE CAP 50MG GENERIC TIER 01LOXAPINE CAP 5MG GENERIC TIER 01LOXITANE CAP 10MG Brand‐O TIER 03 PALOXITANE CAP 25MG Brand‐O TIER 03 PALOXITANE CAP 50MG Brand‐O TIER 03 PALOXITANE CAP 5MG Brand‐O TIER 03 PAORAP TAB 1MG BRAND TIER 02ORAP TAB 2MG BRAND TIER 02ANTIRETROVIRALS, MISCELLANEOUS ATRIPLA TAB BRAND TIER 02ANTITHYROID AGENTS METHIMAZOLE TAB 10MG GENERIC TIER 01METHIMAZOLE TAB 5MG GENERIC TIER 01PROPYLTHIOUR TAB 50MG GENERIC TIER 01SSKI SOL 1GM/ML BRAND TIER 03TAPAZOLE TAB 10MG Brand‐O TIER 03 PATAPAZOLE TAB 5MG Brand‐O TIER 03 PAANTITUBERCULOSIS AGENTS CAPASTAT SUL INJ 1GM BRAND TIER 03CYCLOSERINE CAP 250MG GENERIC TIER 01ETHAMBUTOL TAB 100MG GENERIC TIER 01ETHAMBUTOL TAB 400MG GENERIC TIER 01ISONARIF CAP GENERIC TIER 01ISONIAZID INJ 100MG/ML GENERIC TIER 01ISONIAZID SYP 50MG/5ML GENERIC TIER 01ISONIAZID TAB 100MG GENERIC TIER 01ISONIAZID TAB 300MG GENERIC TIER 01MYAMBUTOL TAB 100MG Brand‐O TIER 03 PAMYAMBUTOL TAB 400MG Brand‐O TIER 03 PAMYCOBUTIN CAP 150MG BRAND TIER 02PASER GRA 4GM BRAND TIER 03PRIFTIN TAB 150MG BRAND TIER 03PYRAZINAMIDE TAB 500MG GENERIC TIER 01RIFADIN CAP 150MG Brand‐O TIER 03 PARIFADIN CAP 300MG Brand‐O TIER 03 PARIFADIN INJ 600 MG Brand‐O TIER 03 PARIFAMATE CAP Brand‐O TIER 03 PARIFAMPIN CAP 150MG GENERIC TIER 01RIFAMPIN CAP 300MG GENERIC TIER 01RIFAMPIN INJ 600 MG GENERIC TIER 01RIFATER TAB BRAND TIER 03Key: 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= DrugExclusion53