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 StatusCENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE TAB 2MG GENERIC TIER 01 PATIZANIDINE TAB 4MG GENERIC TIER 01 PAZANAFLEX CAP 2MG Brand‐O TIER 03 PAZANAFLEX CAP 4MG Brand‐O TIER 03 PAZANAFLEX CAP 6MG Brand‐O TIER 03 PAZANAFLEX TAB 4MG Brand‐O TIER 03 PACEPHAMYCINS CEFOTET/DEX INJ 1‐3.58% GENERIC TIER 01CEFOTET/DEX INJ 2‐2.08% GENERIC TIER 01CEFOTETAN INJ 10G GENERIC TIER 01CEFOTETAN INJ 1GM/10ML GENERIC TIER 01CEFOTETAN INJ 2GM/20ML GENERIC TIER 01CEFOXITIN INJ 10GM GENERIC TIER 01CEFOXITIN INJ 1GM GENERIC TIER 01CEFOXITIN INJ 2GM GENERIC TIER 01MEFOXIN INJ 1GM/50ML BRAND TIER 99 DEMEFOXIN INJ 2GM/50ML BRAND TIER 99 DECHLORAMPHENICOL CHLORAMPHEN INJ 1GM GENERIC TIER 01CHOLELITHOLYTIC AGENTS ACTIGALL CAP 300MG Brand‐O TIER 03 PACHENODAL TAB 250MG BRAND TIER 03URSO 250 TAB 250MG Brand‐O TIER 03 PAURSO FORTE TAB 500MG Brand‐O TIER 03 PAURSODIOL CAP 300MG GENERIC TIER 01URSODIOL TAB 250MG GENERIC TIER 01URSODIOL TAB 500MG GENERIC TIER 01CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB 10MG BRAND TIER 02 PACLASS IA ANTIARRHYTHMICS DISOPYRAMIDE CAP 100MG GENERIC TIER 01DISOPYRAMIDE CAP 150MG GENERIC TIER 01NORPACE CAP 100MG Brand‐O TIER 03 PANORPACE CAP 100MG CR BRAND TIER 03NORPACE CAP 150MG Brand‐O TIER 03 PANORPACE CAP 150MG CR BRAND TIER 03PROCAINAMIDE INJ 100MG/ML GENERIC TIER 01PROCAINAMIDE INJ 500MG/ML GENERIC TIER 01QUINIDINE GL INJ 80MG/ML GENERIC TIER 01QUINIDINE GL TAB 324MG CR GENERIC TIER 01QUINIDINE GL TAB 324MG ER GENERIC TIER 01QUINIDINE SU TAB 200MG GENERIC TIER 01QUINIDINE SU TAB 300MG GENERIC TIER 01QUINIDINE SU TAB 300MG ER 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= DrugExclusion91