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 StatusHEMORRHEOLOGIC AGENTS PENTOXIFYLLI TAB 400MG ER GENERIC TIER 01TRENTAL TAB 400MG CR Brand‐O TIER 03 PAHEMOSTATICS ACTIFOAM MIS 12.7X8.9 BRAND TIER 03ACTIFOAM MIS 7X5X0.6 BRAND TIER 03ADVATE INJ 1000UNIT BRAND TIER 02 SPADVATE INJ 1500UNIT BRAND TIER 02 SPADVATE INJ 2000UNIT BRAND TIER 02 SPADVATE INJ 250UNIT BRAND TIER 02 SPADVATE INJ 3000UNIT BRAND TIER 02 SPADVATE INJ 4000UNIT BRAND TIER 02 SPADVATE INJ 500UNIT BRAND TIER 02 SPALPHANATE INJ VWF/HUM BRAND TIER 02 PA SPALPHANINE SD INJ 1000UNIT BRAND TIER 02 PA SPALPHANINE SD INJ 1500UNIT BRAND TIER 02 PA SPALPHANINE SD INJ 500UNIT BRAND TIER 02 PA SPAMICAR SYP 25% Brand‐O TIER 03 PAAMICAR TAB 1000MG BRAND TIER 03AMICAR TAB 500MG Brand‐O TIER 03 PAAMINOCAPR AC INJ 250MG/ML GENERIC TIER 01AMINOCAPR AC SYP 25% GENERIC TIER 01AMINOCAPR AC TAB 1000MG GENERIC TIER 01AMINOCAPR AC TAB 500MG GENERIC TIER 01ASTRINGYN SOL 259MG/GM BRAND TIER 03AVITENE PAD 35X35MM BRAND TIER 03AVITENE PAD 70X35MM BRAND TIER 03AVITENE PAD 70X70MM BRAND TIER 03AVITENE SYRG MIS 1GM BRAND TIER 03BEBULIN INJ 200‐1200 BRAND TIER 03 PA SPBEBULIN VH INJ 200‐1200 BRAND TIER 03 PA SPBENEFIX INJ 1000UNIT BRAND TIER 02 PA SPBENEFIX INJ 2000UNIT BRAND TIER 02 PA SPBENEFIX INJ 250UNIT BRAND TIER 02 PA SPBENEFIX INJ 3000UNIT BRAND TIER 02 PA SPBENEFIX INJ 500UNIT BRAND TIER 02 PA SPCORIFACT KIT BRAND TIER 02 PA SPCYKLOKAPRON INJ 100MG/ML Brand‐O TIER 03 PAENDO AVITENE MIS 10MM DIA BRAND TIER 03ENDO AVITENE MIS 5MM DIA BRAND TIER 03EVITHROM SOL 800‐1200 BRAND TIER 99 DEKey: 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= DrugExclusion151