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 StatusBETA‐ADRENERGIC BLOCKING AGENTS BETAXOLOL TAB 10MG GENERIC TIER 01BETAXOLOL TAB 20MG GENERIC TIER 01BISOPRL/HCTZ TAB 10/6.25 GENERIC TIER 01BISOPRL/HCTZ TAB 2.5/6.25 GENERIC TIER 01BISOPRL/HCTZ TAB 5‐6.25MG GENERIC TIER 01BISOPROL FUM TAB 10MG GENERIC TIER 01BISOPROL FUM TAB 5MG GENERIC TIER 01BREVIBLOC INJ 10MG/ML Brand‐O TIER 03 PABREVIBLOC SOL BRAND TIER 03BREVIBLOC SOL 10MG/ML BRAND TIER 03BYSTOLIC TAB 10MG BRAND TIER 02 PABYSTOLIC TAB 2.5MG BRAND TIER 02 PABYSTOLIC TAB 20MG BRAND TIER 02 PABYSTOLIC TAB 5MG BRAND TIER 02 PACARVEDILOL TAB 12.5MG GENERIC TIER 01CARVEDILOL TAB 25MG GENERIC TIER 01CARVEDILOL TAB 3.125MG GENERIC TIER 01CARVEDILOL TAB 6.25MG GENERIC TIER 01COREG TAB 12.5MG Brand‐O TIER 03 PACOREG TAB 25MG Brand‐O TIER 03 PACOREG TAB 3.125MG Brand‐O TIER 03 PACOREG TAB 6.25MG Brand‐O TIER 03 PACOREG CR CAP 10MG BRAND TIER 02 PACOREG CR CAP 20MG BRAND TIER 02 PACOREG CR CAP 40MG BRAND TIER 02 PACOREG CR CAP 80MG BRAND TIER 02 PACORGARD TAB 20MG Brand‐O TIER 03 PACORGARD TAB 40MG Brand‐O TIER 03 PACORGARD TAB 80MG Brand‐O TIER 03 PACORZIDE TAB 40‐5MG Brand‐O TIER 03 PACORZIDE TAB 80‐5MG Brand‐O TIER 03 PADUTOPROL TAB 100‐12.5 BRAND TIER 03DUTOPROL TAB 25‐12.5 BRAND TIER 03DUTOPROL TAB 50‐12.5 BRAND TIER 03ESMOLOL HCL INJ 100MG/10 GENERIC TIER 01ESMOLOL HCL INJ 10MG/ML GENERIC TIER 01HYPERTENEVID PAK 12.5MG BRAND TIER 03HYPERTENSOLO PAK BRAND TIER 03INDERAL LA CAP 120MG 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= DrugExclusion71