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 KOGENATE FS INJ 250UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 3000/BS BRAND TIER 02 PA SPKOGENATE FS INJ 3000UNIT BRAND TIER 02 PA SPKOGENATE FS INJ 500/BS BRAND TIER 02 PA SPKOGENATE FS INJ 500UNIT BRAND TIER 02 PA SPLYSTEDA TAB 650MG BRAND TIER 02 PAMONOCLATE‐P INJ 1000UNIT BRAND TIER 02 PA SPMONOCLATE‐P INJ 1500UNIT BRAND TIER 02 PA SPMONOCLATE‐P INJ 250UNIT BRAND TIER 02 PA SPMONOCLATE‐P INJ 500UNIT BRAND TIER 02 PA SPMONONINE INJ 1000UNIT BRAND TIER 02 PA SPMONONINE INJ 250UNIT BRAND TIER 03 PA SPMONONINE INJ 500UNIT BRAND TIER 02 PA SPMONSELS FERR SOL SUBSULF BRAND TIER 99 DENOVOSEVEN INJ 2400MCG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 1MG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 2MG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 5MG BRAND TIER 02 PA SPNOVOSEVEN RT INJ 8MG BRAND TIER 02 PA SPPROFILNINE INJ 1000UNIT BRAND TIER 03 PA SPPROFILNINE INJ 1500UNIT BRAND TIER 03 PA SPPROFILNINE INJ 500UNIT BRAND TIER 03 PA SPRECOMBINATE INJ BRAND TIER 02 PA SPRECOMBINATE INJ 220‐400 BRAND TIER 02 PA SPRECOMBINATE INJ 401‐800 BRAND TIER 02 PA SPRECOMBINATE INJ 801‐1240 BRAND TIER 02 PA SPRECOTHROM SOL 20000UNT BRAND TIER 03RECOTHROM SOL 5000UNIT BRAND TIER 99 DEREFACTO INJ 500UNIT BRAND TIER 02 PA SPRIASTAP SOL 1GM BRAND TIER 03 SPSURGIFOAM MIS 12‐7MM BRAND TIER 03SURGIFOAM MIS SIZE 100 BRAND TIER 03THROMBI‐GEL PAD 10 BRAND TIER 99 DETHROMBI‐GEL PAD 100 BRAND TIER 99 DETHROMBI‐GEL PAD 40 BRAND TIER 99 DETHROMBIN KIT 5000UNIT BRAND TIER 99 DETHROMBIN‐JMI KIT 20000UNT BRAND TIER 99 DETHROMBIN‐JMI KIT 5000UNIT BRAND TIER 99 DETHROMBIN‐JMI SOL 20000UNT 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= DrugExclusion153