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 StatusGONADOTROPINS FOLLISTIM AQ INJ 300UNIT BRAND TIER 99 DEFOLLISTIM AQ INJ 600UNIT BRAND TIER 99 DEFOLLISTIM AQ INJ 75UNIT BRAND TIER 99 DEFOLLISTIM AQ INJ 900UNIT BRAND TIER 99 DEGONAL‐F INJ 1050UNIT BRAND TIER 99 DEGONAL‐F INJ 450UNIT BRAND TIER 99 DEGONAL‐F RFF INJ 300 BRAND TIER 99 DEGONAL‐F RFF INJ 450 BRAND TIER 99 DEGONAL‐F RFF INJ 75UNIT BRAND TIER 99 DEGONAL‐F RFF INJ 900 BRAND TIER 99 DELUVERIS INJ 75UNIT BRAND TIER 99 DEMENOPUR INJ 75UNIT BRAND TIER 99 DENOVAREL INJ 10000UNT GENERIC TIER 99 DEOVIDREL INJ BRAND TIER 99 DEPREGNYL INJ 10000UNT GENERIC TIER 99 DEREPRONEX INJ 75UNIT BRAND TIER 99 DESYNAREL SOL 2MG/ML BRAND TIER 02 SPHCV PROTEASE INHIBITORS INCIVEK TAB 375MG BRAND TIER 02 PA SPVICTRELIS CAP 200MG BRAND TIER 02 PA SPHEAVY METAL ANTAGONISTS BAL IN OIL INJ 100MG/ML BRAND TIER 03CA‐DTPA SOL 1000MG GENERIC TIER 01CALCIUM DISO INJ 500/2.5M GENERIC TIER 01CHEMET CAP 100MG BRAND TIER 02CUPRIMINE CAP 250MG BRAND TIER 02CYANIDE ANTI KIT PKG UNIT GENERIC TIER 01DEFEROXAMINE INJ 2GM GENERIC TIER 01 SPDEFEROXAMINE INJ 500MG GENERIC TIER 01 SPDEPEN TITRA TAB 250MG BRAND TIER 03DESFERAL INJ 2GM Brand‐O TIER 03 PA SPDESFERAL INJ 500MG Brand‐O TIER 03 PA SPENDRATE INJ 150MG/ML BRAND TIER 03EXJADE TAB 125MG BRAND TIER 03 PAEXJADE TAB 250MG BRAND TIER 03 PAEXJADE TAB 500MG BRAND TIER 03 PAFERRIPROX TAB 500MG BRAND TIER 03 PANITHIODOTE KIT BRAND TIER 03SOD NITRITE INJ 30MG/ML GENERIC TIER 01SOD THIOSULF INJ 10% GENERIC TIER 01SOD THIOSULF INJ 25% 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= DrugExclusion149