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 StatusATYPICAL ANTIPSYCHOTICS FANAPT TAB 10MG BRAND TIER 03 PA QLFANAPT TAB 12MG BRAND TIER 03 PA QLFANAPT TAB 1MG BRAND TIER 03 PA QLFANAPT TAB 2MG BRAND TIER 03 PA QLFANAPT TAB 4MG BRAND TIER 03 PA QLFANAPT TAB 6MG BRAND TIER 03 PA QLFANAPT TAB 8MG BRAND TIER 03 PA QLFAZACLO TAB 100MG BRAND TIER 03 PAFAZACLO TAB 12.5MG BRAND TIER 03 PAFAZACLO TAB 150MG BRAND TIER 03 PAFAZACLO TAB 200MG BRAND TIER 03 PAFAZACLO TAB 25MG BRAND TIER 03 PAGEODON CAP 20MG Brand‐O TIER 03 PA QLGEODON CAP 40MG Brand‐O TIER 03 PA QLGEODON CAP 60MG Brand‐O TIER 03 PA QLGEODON CAP 80MG Brand‐O TIER 03 PA QLGEODON INJ 20MG BRAND TIER 03 QLINVEGA TAB 1.5MG BRAND TIER 03 PAINVEGA TAB 3MG BRAND TIER 03 PA QLINVEGA TAB 6MG BRAND TIER 03 PA QLINVEGA TAB 9MG BRAND TIER 03 PA QLINVEGA SUST INJ 117/0.75 BRAND TIER 03INVEGA SUST INJ 156MG/ML BRAND TIER 03INVEGA SUST INJ 234/1.5 BRAND TIER 03INVEGA SUST INJ 39/0.25 BRAND TIER 03INVEGA SUST INJ 78/0.5ML BRAND TIER 03LATUDA TAB 120MG BRAND TIER 02 PALATUDA TAB 20MG BRAND TIER 02 PALATUDA TAB 40MG BRAND TIER 02 PALATUDA TAB 80MG BRAND TIER 02 PAOLANZAPINE INJ 10MG GENERIC TIER 01 QLOLANZAPINE TAB 10MG GENERIC TIER 01 QLOLANZAPINE TAB 10MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 15MG GENERIC TIER 01 QLOLANZAPINE TAB 15MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 2.5MG GENERIC TIER 01 QLOLANZAPINE TAB 20MG GENERIC TIER 01 QLOLANZAPINE TAB 20MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 5MG 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= DrugExclusion61