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 StatusCENTRAL ALPHA‐AGONISTS CLORPRES TAB 0.3‐15MG BRAND TIER 03DURACLON INJ Brand‐O TIER 03 PAGUANABENZ TAB 4MG GENERIC TIER 01GUANFACINE TAB 1MG GENERIC TIER 01GUANFACINE TAB 2MG GENERIC TIER 01KAPVAY MIS 0.1&0.2 BRAND TIER 03KAPVAY TAB 0.1 MG BRAND TIER 03 PA QLMETHYLD/HCTZ TAB 250/15 GENERIC TIER 01METHYLD/HCTZ TAB 250/25 GENERIC TIER 01METHYLDOPA TAB 250MG GENERIC TIER 01METHYLDOPA TAB 500MG GENERIC TIER 01METHYLDOPATE INJ 250/5ML GENERIC TIER 01NEXICLON XR SUS 0.09/ML BRAND TIER 03NEXICLON XR TAB 0.17MG BRAND TIER 03 PATENEX TAB 1MG Brand‐O TIER 03 PATENEX TAB 2MG Brand‐O TIER 03 PACENTRAL NERVOUS SYSTEM AGENTS, MISC. CAMPRAL TAB 333MG BRAND TIER 03FLUMAZENIL INJ 0.1MG/ML GENERIC TIER 01FLUMAZENIL INJ 0.5MG/5 GENERIC TIER 01FLUMAZENIL INJ 1MG/10ML GENERIC TIER 01INTUNIV TAB 1MG BRAND TIER 02 PA QLINTUNIV TAB 2MG BRAND TIER 02 PA QLINTUNIV TAB 3MG BRAND TIER 02 PA QLINTUNIV TAB 4MG BRAND TIER 02 PA QLNAMENDA SOL 10MG/5ML BRAND TIER 02NAMENDA TAB 10MG BRAND TIER 02NAMENDA TAB 5‐10MG BRAND TIER 02NAMENDA TAB 5MG BRAND TIER 02NUEDEXTA CAP 20‐10MG BRAND TIER 02RILUTEK TAB 50MG BRAND TIER 02ROMAZICON INJ 0.1MG/ML Brand‐O TIER 03 PASTRATTERA CAP 100MG BRAND TIER 02 PA QLSTRATTERA CAP 10MG BRAND TIER 02 PA QLSTRATTERA CAP 18MG BRAND TIER 02 PA QLSTRATTERA CAP 25MG BRAND TIER 02 PA QLSTRATTERA CAP 40MG BRAND TIER 02 PA QLSTRATTERA CAP 60MG BRAND TIER 02 PA QLSTRATTERA CAP 80MG BRAND TIER 02 PA QLXENAZINE TAB 12.5MG BRAND TIER 02Key: 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= DrugExclusion89