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 StatusCALCIUM‐CHANNEL BLOCKING AGENTS, MISC. CARDIZEM CD CAP 240MG/24 Brand‐O TIER 03 PACARDIZEM CD CAP 300MG/24 Brand‐O TIER 03 PACARDIZEM CD CAP 360MG/24 Brand‐O TIER 03 PACARDIZEM LA TAB 120MG BRAND TIER 02CARDIZEM LA TAB 180MG Brand‐O TIER 03 PACARDIZEM LA TAB 240MG Brand‐O TIER 03 PACARDIZEM LA TAB 300MG/24 Brand‐O TIER 03 PACARDIZEM LA TAB 360MG Brand‐O TIER 03 PACARDIZEM LA TAB 420MG/24 Brand‐O TIER 03 PACARTIA XT CAP 120/24HR GENERIC TIER 01CARTIA XT CAP 180/24HR GENERIC TIER 01CARTIA XT CAP 240/24HR GENERIC TIER 01CARTIA XT CAP 300/24HR GENERIC TIER 01COVERA‐HS TAB 180MG BRAND TIER 03COVERA‐HS TAB 240MG BRAND TIER 03DILACOR XR CAP 240MG/24 Brand‐O TIER 03 PADILT‐CD CAP 120MG GENERIC TIER 01DILT‐CD CAP 180MG GENERIC TIER 01DILT‐CD CAP 240MG GENERIC TIER 01DILT‐CD CAP 300MG GENERIC TIER 01DILTIAZEM CAP 120MG CD GENERIC TIER 01DILTIAZEM CAP 120MG ER GENERIC TIER 01DILTIAZEM CAP 120MG/24 GENERIC TIER 01DILTIAZEM CAP 180MG CD GENERIC TIER 01DILTIAZEM CAP 180MG ER GENERIC TIER 01DILTIAZEM CAP 180MG/24 GENERIC TIER 01DILTIAZEM CAP 240MG CD GENERIC TIER 01DILTIAZEM CAP 240MG ER GENERIC TIER 01DILTIAZEM CAP 240MG/24 GENERIC TIER 01DILTIAZEM CAP 300MG CD GENERIC TIER 01DILTIAZEM CAP 300MG ER GENERIC TIER 01DILTIAZEM CAP 300MG/24 GENERIC TIER 01DILTIAZEM CAP 360MG CD GENERIC TIER 01DILTIAZEM CAP 360MG ER GENERIC TIER 01DILTIAZEM CAP 360MG/24 GENERIC TIER 01DILTIAZEM CAP 420MG/24 GENERIC TIER 01DILTIAZEM CAP 60MG ER GENERIC TIER 01DILTIAZEM CAP 90MG ER GENERIC TIER 01DILTIAZEM INJ 100MG 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= DrugExclusion78