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 StatusHEMOSTATICS FEIBA NF INJ BRAND TIER 03 PA SPFEIBA VH INJ IMMUNO BRAND TIER 03 PA SPFEIBA VH INJ IMMUNO GENERIC TIER 01 PA SPGELFILM MIS ENVELOPE BRAND TIER 03GELFILM MIS OP BRAND TIER 03GELFOAM MIS DENTAL 4 BRAND TIER 03GELFOAM MIS SPON COM BRAND TIER 03GELFOAM MIS SPONG 50 BRAND TIER 03GELFOAM MIS SPONG100 BRAND TIER 03GELFOAM MIS SPONG200 BRAND TIER 03GELFOAM POW BRAND TIER 03GELFOAM SPNG MIS 12‐7MM BRAND TIER 03HELISTAT MIS 5MM BRAND TIER 03HELIXATE FS INJ 1000UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 2000UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 250UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 3000UNIT BRAND TIER 02 PA SPHELIXATE FS INJ 500UNIT BRAND TIER 02 PA SPHELIXATE FS SOL 1000UNIT BRAND TIER 02 PA SPHELIXATE FS SOL 250UNIT BRAND TIER 02 PA SPHELIXATE FS SOL 500UNIT BRAND TIER 02 PA SPHEMOFIL M INJ 220‐400 BRAND TIER 02 PA SPHEMOFIL M INJ 401‐800 BRAND TIER 02 PA SPHEMOFIL M SOL 501‐2000 BRAND TIER 03 PA SPHEMOFIL M SOL 801‐1500 BRAND TIER 03 PA SPHUMATE‐P INJ 600UNIT BRAND TIER 02 PA SPHUMATE‐P SOL 1200UNIT BRAND TIER 02 PA SPHUMATE‐P SOL 2400UNIT BRAND TIER 02 PA SPHUMATE‐P SOL 600UNIT BRAND TIER 02 PA SPINSTAT PAD 2.5X5.1 BRAND TIER 03INSTAT PAD 7.6X10.2 BRAND TIER 03KOATE‐DVI INJ 1000UNIT BRAND TIER 02 PA SPKOATE‐DVI INJ 250UNIT BRAND TIER 02 PA SPKOATE‐DVI INJ 500UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 1000/BS BRAND TIER 02 PA SPKOGENATE FS INJ 1000UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 2000/BS BRAND TIER 02 PA SPKOGENATE FS INJ 2000UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 250/BS BRAND TIER 02 PA 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= DrugExclusion152