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 StatusBONE RESORPTION INHIBITORS FOSAMAX TAB 5MG Brand‐O TIER 03 PAFOSAMAX TAB 70MG Brand‐O TIER 03 PAFOSAMAX + D TAB 70‐2800 BRAND TIER 03 PAFOSAMAX + D TAB 70‐5600 BRAND TIER 03 PAGANITE INJ 25MG/ML BRAND TIER 03IBANDRONATE TAB 150MG GENERIC TIER 01 PAPAMIDRONATE INJ 30/10ML GENERIC TIER 01PAMIDRONATE INJ 30MG GENERIC TIER 01 SPPAMIDRONATE INJ 6MG/ML GENERIC TIER 01PAMIDRONATE INJ 90/10ML GENERIC TIER 01PAMIDRONATE INJ 90MG GENERIC TIER 01 SPPROLIA SOL 60MG/ML BRAND TIER 03 PA QL SPSKELID TAB 200MG BRAND TIER 03XGEVA INJ BRAND TIER 02 PA QL SPZOMETA INJ 4MG/5ML BRAND TIER 03 SPBUTYROPHENONES HALDOL INJ 5MG/ML Brand‐O TIER 03 PAHALDOL DECAN INJ 100MG/ML Brand‐O TIER 03 PAHALDOL DECAN INJ 50MG/ML Brand‐O TIER 03 PAHALOPER DEC INJ 100MG/ML GENERIC TIER 01HALOPER DEC INJ 50MG/ML GENERIC TIER 01HALOPER LAC INJ 5MG/ML GENERIC TIER 01HALOPERIDOL CON 2MG/ML GENERIC TIER 01HALOPERIDOL TAB 0.5MG GENERIC TIER 01HALOPERIDOL TAB 10MG GENERIC TIER 01HALOPERIDOL TAB 1MG GENERIC TIER 01HALOPERIDOL TAB 20MG GENERIC TIER 01HALOPERIDOL TAB 2MG GENERIC TIER 01HALOPERIDOL TAB 5MG GENERIC TIER 01CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. CALAN TAB 120MG Brand‐O TIER 03 PACALAN TAB 80MG Brand‐O TIER 03 PACALAN SR TAB 120MG Brand‐O TIER 03 PACALAN SR TAB 180MG Brand‐O TIER 03 PACALAN SR TAB 240MG Brand‐O TIER 03 PACARDIZEM TAB 120MG Brand‐O TIER 03 PACARDIZEM TAB 30MG Brand‐O TIER 03 PACARDIZEM TAB 60MG Brand‐O TIER 03 PACARDIZEM TAB 90MG Brand‐O TIER 03 PACARDIZEM CD CAP 120MG/24 Brand‐O TIER 03 PACARDIZEM CD CAP 180MG/24 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= DrugExclusion77