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 StatusBENZODIAZEPINES (ANTICONVULSANTS) ONFI TAB 10MG BRAND TIER 03ONFI TAB 20MG BRAND TIER 03ONFI TAB 5MG BRAND TIER 03BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) ALPRAZOLAM CON 1 MG/ML BRAND TIER 03ALPRAZOLAM TAB 0.25 ODT GENERIC TIER 01ALPRAZOLAM TAB 0.25MG GENERIC TIER 01ALPRAZOLAM TAB 0.5MG GENERIC TIER 01ALPRAZOLAM TAB 0.5MG ER GENERIC TIER 01ALPRAZOLAM TAB 0.5MG OD GENERIC TIER 01ALPRAZOLAM TAB 1MG GENERIC TIER 01ALPRAZOLAM TAB 1MG ER GENERIC TIER 01ALPRAZOLAM TAB 1MG ODT GENERIC TIER 01ALPRAZOLAM TAB 2MG GENERIC TIER 01ALPRAZOLAM TAB 2MG ER GENERIC TIER 01ALPRAZOLAM TAB 2MG ODT GENERIC TIER 01ALPRAZOLAM TAB 3MG ER GENERIC TIER 01ALPRAZOLAM TAB XR 0.5MG GENERIC TIER 01ALPRAZOLAM TAB XR 1MG GENERIC TIER 01ALPRAZOLAM TAB XR 2MG GENERIC TIER 01ALPRAZOLAM TAB XR 3MG GENERIC TIER 01ATIVAN INJ 2MG/ML Brand‐O TIER 03 PA SPATIVAN INJ 4MG/ML Brand‐O TIER 03 PA SPATIVAN TAB 0.5MG Brand‐O TIER 03 PAATIVAN TAB 1MG Brand‐O TIER 03 PAATIVAN TAB 2MG Brand‐O TIER 03 PACHLORDIAZEP CAP 10MG GENERIC TIER 01CHLORDIAZEP CAP 25MG GENERIC TIER 01CHLORDIAZEP CAP 5MG GENERIC TIER 01CLORAZ DIPOT TAB 15MG GENERIC TIER 01CLORAZ DIPOT TAB 3.75MG GENERIC TIER 01CLORAZ DIPOT TAB 7.5MG GENERIC TIER 01DIASTAT ACDL GEL 12.5‐20 BRAND TIER 03DIASTAT ACDL GEL 5‐10MG BRAND TIER 03DIASTAT PED GEL 2.5M GEL BRAND TIER 02DIAZEPAM CON 5MG/ML BRAND TIER 03DIAZEPAM GEL 10MG GENERIC TIER 01DIAZEPAM GEL 2.5MG GENERIC TIER 01DIAZEPAM GEL 20MG GENERIC TIER 01DIAZEPAM INJ 10MG/2ML GENERIC TIER 01Key: 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= DrugExclusion68