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 PROPRANOLOL CAP 160MG ER GENERIC TIER 01PROPRANOLOL CAP 60MG ER GENERIC TIER 01PROPRANOLOL CAP 80MG ER GENERIC TIER 01PROPRANOLOL INJ 1MG/ML GENERIC TIER 01PROPRANOLOL SOL 20MG/5ML GENERIC TIER 01PROPRANOLOL SOL 40MG/5ML GENERIC TIER 01PROPRANOLOL TAB 10MG GENERIC TIER 01PROPRANOLOL TAB 20MG GENERIC TIER 01PROPRANOLOL TAB 40MG GENERIC TIER 01PROPRANOLOL TAB 60MG GENERIC TIER 01PROPRANOLOL TAB 80MG GENERIC TIER 01SECTRAL CAP 200MG Brand‐O TIER 03 PASECTRAL CAP 400MG Brand‐O TIER 03 PASORINE TAB 120MG GENERIC TIER 01SORINE TAB 160MG GENERIC TIER 01SORINE TAB 240MG GENERIC TIER 01SORINE TAB 80MG GENERIC TIER 01SOTALOL AF TAB 120MG GENERIC TIER 01SOTALOL AF TAB 160MG GENERIC TIER 01SOTALOL AF TAB 80MG GENERIC TIER 01SOTALOL HCL INJ 150/10ML GENERIC TIER 01SOTALOL HCL TAB 120MG GENERIC TIER 01SOTALOL HCL TAB 160MG GENERIC TIER 01SOTALOL HCL TAB 240MG GENERIC TIER 01SOTALOL HCL TAB 80MG GENERIC TIER 01TENORETIC TAB 100 Brand‐O TIER 03 PATENORETIC TAB 50 Brand‐O TIER 03 PATENORMIN TAB 100MG Brand‐O TIER 03 PATENORMIN TAB 25MG Brand‐O TIER 03 PATENORMIN TAB 50MG Brand‐O TIER 03 PATIMOLOL MAL TAB 10MG GENERIC TIER 01TIMOLOL MAL TAB 20MG GENERIC TIER 01TIMOLOL MAL TAB 5MG GENERIC TIER 01TOPROL XL TAB 100MG Brand‐O TIER 03 PATOPROL XL TAB 200MG Brand‐O TIER 03 PATOPROL XL TAB 25MG Brand‐O TIER 03 PATOPROL XL TAB 50MG Brand‐O TIER 03 PATRANDATE TAB 100MG Brand‐O TIER 03 PATRANDATE TAB 200MG 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= DrugExclusion73