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 StatusIMMUNOSUPPRESSIVE AGENTS AZATHIOPRINE TAB 50MG GENERIC TIER 01BENLYSTA INJ 120MG BRAND TIER 03 PABENLYSTA INJ 400MG BRAND TIER 03 PACELLCEPT CAP 250MG Brand‐O TIER 03 PACELLCEPT SUS 200MG/ML BRAND TIER 02CELLCEPT TAB 500MG Brand‐O TIER 03 PACELLCEPT IV INJ 500MG BRAND TIER 03CYCLOSPORINE CAP 100MG GENERIC TIER 01CYCLOSPORINE CAP 100MG MD GENERIC TIER 01CYCLOSPORINE CAP 25MG GENERIC TIER 01CYCLOSPORINE CAP 25MG MOD GENERIC TIER 01CYCLOSPORINE CAP 50MG MOD GENERIC TIER 01CYCLOSPORINE INJ 50MG/ML GENERIC TIER 01CYCLOSPORINE SOL MODIFIED GENERIC TIER 01GENGRAF CAP 100MG GENERIC TIER 01GENGRAF CAP 25MG GENERIC TIER 01GENGRAF SOL 100MG/ML GENERIC TIER 01HECORIA CAP 0.5MG GENERIC TIER 01HECORIA CAP 1MG GENERIC TIER 01HECORIA CAP 5MG GENERIC TIER 01IMURAN TAB 50MG Brand‐O TIER 03 PAMYCOPHENOLAT CAP 250MG GENERIC TIER 01MYCOPHENOLAT TAB 500MG GENERIC TIER 01MYFORTIC TAB 180MG BRAND TIER 03MYFORTIC TAB 360MG BRAND TIER 03NEORAL CAP 100MG Brand‐O TIER 02 PANEORAL CAP 25MG Brand‐O TIER 02 PANEORAL SOL 100MG/ML Brand‐O TIER 02 PANULOJIX INJ 250MG BRAND TIER 03ORTHOCLONE INJ OKT3 BRAND TIER 03PROGRAF CAP 0.5MG Brand‐O TIER 03 PAPROGRAF CAP 1MG Brand‐O TIER 03 PAPROGRAF CAP 5MG Brand‐O TIER 03 PAPROGRAF INJ 5MG/ML BRAND TIER 03 SPRAPAMUNE SOL 1MG/ML BRAND TIER 02RAPAMUNE TAB 0.5MG BRAND TIER 02RAPAMUNE TAB 1MG BRAND TIER 02RAPAMUNE TAB 2MG BRAND TIER 02SANDIMMUNE CAP 100MG Brand‐O TIER 02 PAKey: 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= DrugExclusion160