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. DILTIAZEM INJ 125/25ML GENERIC TIER 01DILTIAZEM INJ 25MG/5ML GENERIC TIER 01DILTIAZEM INJ 50/10ML GENERIC TIER 01DILTIAZEM TAB 120MG GENERIC TIER 01DILTIAZEM TAB 30MG GENERIC TIER 01DILTIAZEM TAB 60MG GENERIC TIER 01DILTIAZEM TAB 90MG GENERIC TIER 01DILT‐XR CAP 120MG GENERIC TIER 01DILT‐XR CAP 180MG GENERIC TIER 01DILT‐XR CAP 240MG GENERIC TIER 01DILTZAC CAP 120MG/24 GENERIC TIER 01DILTZAC CAP 180MG/24 GENERIC TIER 01DILTZAC CAP 240MG/24 GENERIC TIER 01DILTZAC CAP 300MG/24 GENERIC TIER 01DILTZAC CAP 360MG/24 GENERIC TIER 01ISOPTIN SR TAB 120MG Brand‐O TIER 03 PAISOPTIN SR TAB 180MG Brand‐O TIER 03 PAISOPTIN SR TAB 240MG Brand‐O TIER 03 PAMATZIM LA TAB 180MG/24 GENERIC TIER 01MATZIM LA TAB 240MG/24 GENERIC TIER 01MATZIM LA TAB 300MG/24 GENERIC TIER 01MATZIM LA TAB 360MG/24 GENERIC TIER 01MATZIM LA TAB 420MG/24 GENERIC TIER 01TARKA TAB 1‐240 CR BRAND TIER 02TARKA TAB 2‐180 CR BRAND TIER 02TARKA TAB 2‐240 CR BRAND TIER 02TARKA TAB 4‐240 CR BRAND TIER 02TAZTIA XT CAP 120MG/24 GENERIC TIER 01TAZTIA XT CAP 180MG/24 GENERIC TIER 01TAZTIA XT CAP 240MG/24 GENERIC TIER 01TAZTIA XT CAP 300MG/24 GENERIC TIER 01TAZTIA XT CAP 360MG/24 GENERIC TIER 01TIAZAC CAP 120MG/24 Brand‐O TIER 03 PATIAZAC CAP 180MG/24 Brand‐O TIER 03 PATIAZAC CAP 240MG/24 Brand‐O TIER 03 PATIAZAC CAP 300MG/24 Brand‐O TIER 03 PATIAZAC CAP 360MG/24 Brand‐O TIER 03 PATIAZAC CAP 420MG/24 Brand‐O TIER 03 PATRANDO/VERAP TAB 1‐240 CR 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= DrugExclusion79