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 NERVOUS SYSTEM AGENTS, MISC. XENAZINE TAB 25MG BRAND TIER 02XYREM SOL 500MG/ML BRAND TIER 02CENTRALLY ACTING SKELETAL MUSCLE RELAXNT AMRIX CAP 15MG BRAND TIER 03 PAAMRIX CAP 30MG BRAND TIER 03 PACARISOPR/ASA TAB 200‐325 GENERIC TIER 01 QLCARISOPRODOL TAB 250MG GENERIC TIER 01 PA QLCARISOPRODOL TAB 350MG GENERIC TIER 01 QLCARISOPRODOL TAB ASA/COD GENERIC TIER 01CHLORZOXAZON TAB 500MG GENERIC TIER 01CYCLOBENZAPR CAP 15MG ER GENERIC TIER 01 PACYCLOBENZAPR CAP 30MG ER GENERIC TIER 01 PACYCLOBENZAPR CRE 20MG/GM GENERIC TIER 01CYCLOBENZAPR KIT COMFORT BRAND TIER 03CYCLOBENZAPR TAB 10MG GENERIC TIER 01CYCLOBENZAPR TAB 5MG GENERIC TIER 01CYCLOBENZAPR TAB 7.5MG GENERIC TIER 01 PAFEXMID TAB 7.5MG Brand‐O TIER 03 PAFLEXERIL TAB 10MG Brand‐O TIER 03 PAFLEXERIL TAB 5MG Brand‐O TIER 03 PALORZONE TAB 375MG BRAND TIER 03LORZONE TAB 750MG BRAND TIER 03METAXALONE TAB 800MG GENERIC TIER 01 PAMETHOCARBAM TAB 500MG GENERIC TIER 01METHOCARBAM TAB 750MG GENERIC TIER 01PARAFON FORT TAB DSC Brand‐O TIER 03 PAPRAZOLAMINE PAK BRAND TIER 03ROBAXIN INJ 100MG/ML BRAND TIER 03ROBAXIN TAB 500MG Brand‐O TIER 03 PAROBAXIN‐750 TAB 750MG Brand‐O TIER 03 PASKELAXIN TAB 800MG Brand‐O TIER 03 PASOMA TAB 250MG BRAND TIER 03 PA QLSOMA TAB 350MG Brand‐O TIER 03 PA QLTHERABENZAPR PAK ‐60 BRAND TIER 03THERABENZAPR PAK ‐90 BRAND TIER 03THERABENZAPR PAK ‐90‐5 BRAND TIER 03TIZANIDINE CAP 2MG GENERIC TIER 01 PATIZANIDINE CAP 4MG GENERIC TIER 01 PATIZANIDINE CAP 6MG GENERIC TIER 01 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= DrugExclusion90