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 (ANXIOLYTIC,SEDATIV/HYP) DIAZEPAM INJ 5MG/ML GENERIC TIER 01DIAZEPAM SOL 1MG/ML GENERIC TIER 01DIAZEPAM TAB 10MG GENERIC TIER 01DIAZEPAM TAB 2MG GENERIC TIER 01DIAZEPAM TAB 5MG GENERIC TIER 01DORAL TAB 15MG BRAND TIER 03ESTAZOLAM TAB 1MG GENERIC TIER 01ESTAZOLAM TAB 2MG GENERIC TIER 01FLURAZEPAM CAP 15MG GENERIC TIER 01FLURAZEPAM CAP 30MG GENERIC TIER 01GABAVALE‐5 PAK BRAND TIER 03GABAZOLAMINE PAK BRAND TIER 03GABAZOLAMINE PAK 0.5MG BRAND TIER 03HALCION TAB 0.25MG Brand‐O TIER 03 PALORAZEPAM CON 2MG/ML Brand‐O TIER 03 PALORAZEPAM CON 2MG/ML GENERIC TIER 01LORAZEPAM INJ 2MG/ML GENERIC TIER 01 SPLORAZEPAM INJ 4MG/ML GENERIC TIER 01 SPLORAZEPAM TAB 0.5MG GENERIC TIER 01LORAZEPAM TAB 1MG GENERIC TIER 01LORAZEPAM TAB 2MG GENERIC TIER 01MIDAZOLAM INJ 10MG/10 GENERIC TIER 01MIDAZOLAM INJ 10MG/2ML GENERIC TIER 01MIDAZOLAM INJ 1MG/ML GENERIC TIER 01MIDAZOLAM INJ 25MG/5ML GENERIC TIER 01MIDAZOLAM INJ 2MG/2ML GENERIC TIER 01MIDAZOLAM INJ 50MG/10 GENERIC TIER 01MIDAZOLAM INJ 5MG/5ML GENERIC TIER 01MIDAZOLAM INJ 5MG/ML GENERIC TIER 01MIDAZOLAM SYP 2MG/ML GENERIC TIER 01NIRAVAM TAB 0.25MG Brand‐O TIER 03 PANIRAVAM TAB 0.5MG Brand‐O TIER 03 PANIRAVAM TAB 1MG Brand‐O TIER 03 PANIRAVAM TAB 2MG Brand‐O TIER 03 PAOXAZEPAM CAP 10MG GENERIC TIER 01OXAZEPAM CAP 15MG GENERIC TIER 01OXAZEPAM CAP 30MG GENERIC TIER 01RESTORIL CAP 15MG Brand‐O TIER 03 PARESTORIL CAP 22.5MG Brand‐O TIER 03 PAKey: 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= DrugExclusion69