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 SANDIMMUNE CAP 25MG Brand‐O TIER 02 PASANDIMMUNE INJ 50MG/ML Brand‐O TIER 03 PASANDIMMUNE SOL 100MG/ML BRAND TIER 02SIMULECT INJ 10MG BRAND TIER 03 SPSIMULECT INJ 20MG BRAND TIER 03 SPTACROLIMUS CAP 0.5MG GENERIC TIER 01TACROLIMUS CAP 1MG GENERIC TIER 01TACROLIMUS CAP 5MG GENERIC TIER 01THYMOGLOBULN INJ 25MG BRAND TIER 03 SPZORTRESS TAB 0.25MG BRAND TIER 03ZORTRESS TAB 0.5MG BRAND TIER 03ZORTRESS TAB 0.75MG BRAND TIER 03INCRETIN MIMETICS BYDUREON INJ BRAND TIER 02 PABYETTA INJ 10MCG BRAND TIER 02 PABYETTA INJ 5MCG BRAND TIER 02 PAVICTOZA INJ 18MG/3ML BRAND TIER 02 PAINHALATION ANESTHETICS COMPOUND 347 LIQ GENERIC TIER 01ETHRANE INH Brand‐O TIER 03 PAFORANE SOL Brand‐O TIER 03 PAISOFLURANE SOL GENERIC TIER 01SEVOFLURANE SOL GENERIC TIER 01SOJOURN SOL GENERIC TIER 01SUPRANE INH BRAND TIER 03SUPRANE SOL BRAND TIER 03TERRELL SOL GENERIC TIER 01ULTANE SOL Brand‐O TIER 03 PAINSULINS APIDRA INJ SOLOSTAR BRAND TIER 02APIDRA INJ U‐100 BRAND TIER 02HUMALOG INJ 100/ML BRAND TIER 02HUMALOG KWIK INJ 100/ML BRAND TIER 02HUMALOG MIX INJ 50/50 BRAND TIER 02HUMALOG MIX INJ 50/50KWP BRAND TIER 02HUMALOG MIX INJ 75/25KWP BRAND TIER 02HUMALOG MIX SUS 75/25 BRAND TIER 02HUMULIN R INJ U‐500 BRAND TIER 02LANTUS INJ 100/ML BRAND TIER 02LANTUS INJ SOLOSTAR BRAND TIER 02LEVEMIR INJ BRAND TIER 02LEVEMIR INJ FLEXPEN BRAND TIER 02Key: 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= DrugExclusion161