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 StatusALPHA‐ AND BETA‐ADRENERGIC AGONISTS LEVOPHED INJ 1MG/ML GENERIC TIER 01NOREPINEPHR INJ 1MG/ML GENERIC TIER 01PSEUDOEPHEDR CRY HCL GENERIC TIER 99 DERESPIVENT‐D TAB GENERIC TIER 99 DETWINJECT INJ 0.15MG BRAND TIER 03TWINJECT INJ 0.3MG BRAND TIER 02 QLALLERX‐D TAB 120/2.5 Brand‐O TIER 99 PA DEALPHA‐ADRENERGIC AGONISTS LUSONAL LIQ BRAND TIER 03MIDODRINE TAB 10MG GENERIC TIER 01MIDODRINE TAB 2.5MG GENERIC TIER 01MIDODRINE TAB 5MG GENERIC TIER 01NEO‐SYNEPHRI INJ 10MG/ML Brand‐O TIER 03 PAPHENYLEPHRIN CRY GENERIC TIER 99 DEPHENYLEPHRIN INJ 10MG/ML GENERIC TIER 01ALPHA‐ADRENERGIC AGONISTS (EENT) ALPHAGAN P SOL 0.1% BRAND TIER 02ALPHAGAN P SOL 0.15% Brand‐O TIER 03 PABRIMONIDINE SOL 0.15% GENERIC TIER 01BRIMONIDINE SOL 0.2% OP GENERIC TIER 01COMBIGAN SOL 0.2/0.5% BRAND TIER 03ALPHA‐ADRENERGIC BLOCKING AGENTS CARDURA TAB 1MG Brand‐O TIER 03 PACARDURA TAB 2MG Brand‐O TIER 03 PACARDURA TAB 4MG Brand‐O TIER 03 PACARDURA TAB 8MG Brand‐O TIER 03 PACARDURA XL TAB 4MG BRAND TIER 03 PA QLCARDURA XL TAB 8MG BRAND TIER 03 PA QLDOXAZOSIN TAB 1MG GENERIC TIER 01DOXAZOSIN TAB 2MG GENERIC TIER 01DOXAZOSIN TAB 4MG GENERIC TIER 01DOXAZOSIN TAB 8MG GENERIC TIER 01MINIPRESS CAP 1MG Brand‐O TIER 03 PAMINIPRESS CAP 2MG Brand‐O TIER 03 PAMINIPRESS CAP 5MG Brand‐O TIER 03 PAPRAZOSIN HCL CAP 1MG GENERIC TIER 01PRAZOSIN HCL CAP 2MG GENERIC TIER 01PRAZOSIN HCL CAP 5MG GENERIC TIER 01TERAZOSIN CAP 10MG GENERIC TIER 01TERAZOSIN CAP 1MG GENERIC TIER 01TERAZOSIN CAP 2MG GENERIC TIER 01TERAZOSIN CAP 5MG 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= DrugExclusion7