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 StatusHEAVY METAL ANTAGONISTS SYPRINE CAP 250MG BRAND TIER 03ZN‐DTPA SOL 1000MG GENERIC TIER 01HEMATOPOIETIC AGENTS ARANESP INJ 100MCG BRAND TIER 02 PA SPARANESP INJ 150MCG BRAND TIER 02 PA SPARANESP INJ 200MCG BRAND TIER 02 PA SPARANESP INJ 25MCG BRAND TIER 02 PA SPARANESP INJ 300MCG BRAND TIER 02 PA SPARANESP INJ 40MCG BRAND TIER 02 PA SPARANESP INJ 500MCG BRAND TIER 02 PA SPARANESP INJ 60MCG BRAND TIER 02 PA SPEPOGEN INJ 10000/ML BRAND TIER 03 PA SPEPOGEN INJ 2000/ML BRAND TIER 03 PA SPEPOGEN INJ 20000/ML BRAND TIER 03 PA SPEPOGEN INJ 3000/ML BRAND TIER 03 PA SPEPOGEN INJ 4000/ML BRAND TIER 03 PA SPLEUKINE INJ 250MCG BRAND TIER 02LEUKINE INJ 500 MCG BRAND TIER 02MOZOBIL INJ BRAND TIER 02 PA SPNEULASTA INJ 6MG/0.6M BRAND TIER 02 SPNEUMEGA INJ 5MG BRAND TIER 02NEUPOGEN INJ 300/0.5 BRAND TIER 02 SPNEUPOGEN INJ 300MCG BRAND TIER 02 SPNEUPOGEN INJ 480/0.8 BRAND TIER 02 SPNEUPOGEN INJ 480MCG BRAND TIER 02 SPNPLATE INJ 250MCG BRAND TIER 02 PA SPNPLATE INJ 500MCG BRAND TIER 02 PA SPOMONTYS INJ 10MG/ML BRAND TIER 03 SPOMONTYS INJ 20MG/2ML BRAND TIER 03 SPPROCRIT INJ 10000/ML BRAND TIER 02 PA SPPROCRIT INJ 2000/ML BRAND TIER 02 PA SPPROCRIT INJ 20000/ML BRAND TIER 02 PA SPPROCRIT INJ 3000/ML BRAND TIER 02 PA SPPROCRIT INJ 4000/ML BRAND TIER 02 PA SPPROCRIT INJ 40000/ML BRAND TIER 02 PA SPPROMACTA TAB 12.5MG BRAND TIER 02 PA SPPROMACTA TAB 25MG BRAND TIER 02 PA SPPROMACTA TAB 50MG BRAND TIER 02 PA SPPROMACTA TAB 75MG BRAND TIER 02 PA SPHEMORRHEOLOGIC AGENTS PENTOPAK TAB 400MG CR 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= DrugExclusion150