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 OLANZAPINE TAB 5MG ODT GENERIC TIER 01 PA QLOLANZAPINE TAB 7.5MG GENERIC TIER 01 QLQUETIAPINE TAB 100MG GENERIC TIER 01 QLQUETIAPINE TAB 200MG GENERIC TIER 01 QLQUETIAPINE TAB 25MG GENERIC TIER 01 QLQUETIAPINE TAB 300MG GENERIC TIER 01 QLQUETIAPINE TAB 400MG GENERIC TIER 01 QLQUETIAPINE TAB 50MG GENERIC TIER 01 QLRISPERDAL INJ 12.5MG BRAND TIER 03 QLRISPERDAL INJ 25MG BRAND TIER 03 QLRISPERDAL INJ 37.5MG BRAND TIER 03 QLRISPERDAL INJ 50MG BRAND TIER 03 QLRISPERDAL SOL 1MG/ML Brand‐O TIER 03 PA QLRISPERDAL TAB 0.25MG Brand‐O TIER 03 PA QLRISPERDAL TAB 0.5MG Brand‐O TIER 03 PA QLRISPERDAL TAB 1MG Brand‐O TIER 03 PA QLRISPERDAL TAB 2MG Brand‐O TIER 03 PA QLRISPERDAL TAB 3MG Brand‐O TIER 03 PA QLRISPERDAL TAB 4MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 0.5MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 1MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 2MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 3MG Brand‐O TIER 03 PA QLRISPERDAL M TAB 4MG Brand‐O TIER 03 PA QLRISPERIDONE SOL 1MG/ML GENERIC TIER 01 QLRISPERIDONE TAB 0.25 ODT GENERIC TIER 01 PARISPERIDONE TAB 0.25MG GENERIC TIER 01 QLRISPERIDONE TAB 0.5MG GENERIC TIER 01 QLRISPERIDONE TAB 0.5MG OD GENERIC TIER 01 PA QLRISPERIDONE TAB 1MG GENERIC TIER 01 QLRISPERIDONE TAB 1MG ODT GENERIC TIER 01 PA QLRISPERIDONE TAB 2MG GENERIC TIER 01 QLRISPERIDONE TAB 2MG ODT GENERIC TIER 01 PA QLRISPERIDONE TAB 3MG GENERIC TIER 01 QLRISPERIDONE TAB 3MG ODT GENERIC TIER 01 PA QLRISPERIDONE TAB 4MG GENERIC TIER 01 QLRISPERIDONE TAB 4MG ODT GENERIC TIER 01 PA QLSAPHRIS SUB 10MG BRAND TIER 03 PA QLSAPHRIS SUB 5MG BRAND TIER 03 PA 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= DrugExclusion62