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) RESTORIL CAP 30MG Brand‐O TIER 03 PARESTORIL CAP 7.5MG Brand‐O TIER 03 PASENTRAZOLAM PAK AM 0.25 BRAND TIER 03STRAZEPAM PAK BRAND TIER 03TEMAZEPAM CAP 15MG GENERIC TIER 01TEMAZEPAM CAP 22.5MG GENERIC TIER 01TEMAZEPAM CAP 30MG GENERIC TIER 01TEMAZEPAM CAP 7.5MG GENERIC TIER 01TRANXENE T TAB 15MG Brand‐O TIER 03 PATRANXENE T TAB 3.75MG Brand‐O TIER 03 PATRANXENE T TAB 7.5MG Brand‐O TIER 03 PATRIAZOLAM TAB 0.125MG GENERIC TIER 01TRIAZOLAM TAB 0.25MG GENERIC TIER 01VALIUM TAB 10MG Brand‐O TIER 03 PAVALIUM TAB 2MG Brand‐O TIER 03 PAVALIUM TAB 5MG Brand‐O TIER 03 PAXANAX TAB 0.25MG Brand‐O TIER 03 PAXANAX TAB 0.5MG Brand‐O TIER 03 PAXANAX TAB 1MG Brand‐O TIER 03 PAXANAX TAB 2MG Brand‐O TIER 03 PAXANAX XR TAB 0.5MG Brand‐O TIER 03 PAXANAX XR TAB 1MG Brand‐O TIER 03 PAXANAX XR TAB 2MG Brand‐O TIER 03 PAXANAX XR TAB 3MG Brand‐O TIER 03 PABENZYLAMINES (SKIN & MUCOUS MEMBRANE) MENTAX CRE 1% BRAND TIER 02BETA‐ADRENERGIC BLOCKING AGENTS ACEBUTOLOL CAP 200MG GENERIC TIER 01ACEBUTOLOL CAP 400MG GENERIC TIER 01ATENOL/CHLOR TAB 100‐25MG GENERIC TIER 01ATENOL/CHLOR TAB 50‐25MG GENERIC TIER 01ATENOLOL TAB 100MG GENERIC TIER 01ATENOLOL TAB 25MG GENERIC TIER 01ATENOLOL TAB 50MG GENERIC TIER 01BETAPACE TAB 120MG Brand‐O TIER 03 PABETAPACE TAB 160MG Brand‐O TIER 03 PABETAPACE TAB 80MG Brand‐O TIER 03 PABETAPACE AF TAB 120MG Brand‐O TIER 03 PABETAPACE AF TAB 160MG Brand‐O TIER 03 PABETAPACE AF TAB 80MG 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= DrugExclusion70