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 StatusCLASS IB ANTIARRHYTHMICS LIDOCAIN/D5W INJ 4MG/ML GENERIC TIER 01LIDOCAIN/D5W INJ 8MG/ML GENERIC TIER 01LIDOCAINE INJ 10MG/ML GENERIC TIER 01LIDOCAINE INJ 20MG/ML GENERIC TIER 01MEXILETINE CAP 150MG GENERIC TIER 01MEXILETINE CAP 200MG GENERIC TIER 01MEXILETINE CAP 250MG GENERIC TIER 01CLASS IC ANTIARRHYTHMICS FLECAINIDE TAB 100MG GENERIC TIER 01FLECAINIDE TAB 150MG GENERIC TIER 01FLECAINIDE TAB 50MG GENERIC TIER 01PROPAFENONE CAP 225MG ER GENERIC TIER 01PROPAFENONE CAP 325MG ER GENERIC TIER 01PROPAFENONE CAP 425MG SR GENERIC TIER 01PROPAFENONE TAB 150MG GENERIC TIER 01PROPAFENONE TAB 225MG GENERIC TIER 01PROPAFENONE TAB 300MG GENERIC TIER 01RYTHMOL TAB 150MG Brand‐O TIER 03 PARYTHMOL TAB 225MG Brand‐O TIER 03 PARYTHMOL SR CAP 225MG Brand‐O TIER 03 PARYTHMOL SR CAP 325MG Brand‐O TIER 03 PARYTHMOL SR CAP 425MG Brand‐O TIER 03 PATAMBOCOR TAB 100MG Brand‐O TIER 03 PATAMBOCOR TAB 150MG Brand‐O TIER 03 PATAMBOCOR TAB 50MG Brand‐O TIER 03 PACLASS III ANTIARRHYTHMICS AMIODARONE INJ 150MG/3M GENERIC TIER 01AMIODARONE INJ 50MG/ML GENERIC TIER 01AMIODARONE TAB 200MG GENERIC TIER 01AMIODARONE TAB 400MG GENERIC TIER 01CORDARONE TAB 200MG Brand‐O TIER 03 PACORVERT INJ 1MG/10ML Brand‐O TIER 03 PAIBUTILIDE INJ 1MG/10ML GENERIC TIER 01MULTAQ TAB 400MG BRAND TIER 02NEXTERONE INJ BRAND TIER 99 DEPACERONE TAB 100MG BRAND TIER 02PACERONE TAB 200MG GENERIC TIER 01PACERONE TAB 400MG Brand‐O TIER 03 PATIKOSYN CAP 125MCG BRAND TIER 02 SPTIKOSYN CAP 250MCG BRAND TIER 02 SPTIKOSYN CAP 500MCG BRAND TIER 02 SPKey: 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= DrugExclusion92