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 INDERAL LA CAP 160MG Brand‐O TIER 03 PAINDERAL LA CAP 60MG Brand‐O TIER 03 PAINDERAL LA CAP 80MG Brand‐O TIER 03 PAINNOPRAN XL CAP 120MG BRAND TIER 03INNOPRAN XL CAP 80MG BRAND TIER 03KERLONE TAB 10MG Brand‐O TIER 03 PAKERLONE TAB 20MG Brand‐O TIER 03 PALABETALOL INJ 5MG/ML GENERIC TIER 01LABETALOL TAB 100MG GENERIC TIER 01LABETALOL TAB 200MG GENERIC TIER 01LABETALOL TAB 300MG GENERIC TIER 01LEVATOL TAB 20MG BRAND TIER 03LOPRESS HCT TAB 100‐25MG Brand‐O TIER 03 PALOPRESS HCT TAB 50‐25MG Brand‐O TIER 03 PALOPRESSOR INJ 5MG/5ML Brand‐O TIER 03 PALOPRESSOR TAB 100MG Brand‐O TIER 03 PALOPRESSOR TAB 50MG Brand‐O TIER 03 PAMETOPRL/HCTZ TAB 100‐25MG GENERIC TIER 01METOPRL/HCTZ TAB 100‐50MG GENERIC TIER 01METOPRL/HCTZ TAB 50‐25MG GENERIC TIER 01METOPROL TAR TAB 100MG GENERIC TIER 01METOPROL TAR TAB 25MG GENERIC TIER 01METOPROL TAR TAB 50MG GENERIC TIER 01METOPROLOL INJ 1MG/ML GENERIC TIER 01METOPROLOL INJ 5MG/5ML GENERIC TIER 01METOPROLOL TAB 100MG ER GENERIC TIER 01METOPROLOL TAB 200MG ER GENERIC TIER 01METOPROLOL TAB 25MG ER GENERIC TIER 01METOPROLOL TAB 50MG ER GENERIC TIER 01NADOLOL TAB 20MG GENERIC TIER 01NADOLOL TAB 40MG GENERIC TIER 01NADOLOL TAB 80MG GENERIC TIER 01NADOLOL/BEND TAB 40‐5MG GENERIC TIER 01NADOLOL/BEND TAB 80‐5MG GENERIC TIER 01PINDOLOL TAB 10MG GENERIC TIER 01PINDOLOL TAB 5MG GENERIC TIER 01PROPRAN/HCTZ TAB 40/25 GENERIC TIER 01PROPRAN/HCTZ TAB 80/25 GENERIC TIER 01PROPRANOLOL CAP 120MG ER 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= DrugExclusion72