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 StatusINSULINS NOVOLOG INJ 100/ML BRAND TIER 02NOVOLOG INJ FLEXPEN BRAND TIER 02NOVOLOG INJ PENFILL BRAND TIER 02NOVOLOG MIX INJ 70/30 BRAND TIER 02NOVOLOG MIX INJ FLEXPEN BRAND TIER 02INTEGRASE INHIBITORS ISENTRESS CHW 100MG BRAND TIER 02ISENTRESS CHW 25MG BRAND TIER 02ISENTRESS TAB 400MG BRAND TIER 02STRIBILD TAB BRAND TIER 03INTERFERONS INFERGEN INJ 15MCG BRAND TIER 03 PA SPINFERGEN INJ 9MCG BRAND TIER 03 PA SPPEGASYS INJ BRAND TIER 02 PA SPPEGASYS INJ 180MCG/M BRAND TIER 02 PA SPPEGASYS INJ PROCLICK BRAND TIER 02 PA SPPEGASYS KIT BRAND TIER 02 PA SPPEG‐INTRON KIT 120 RP BRAND TIER 02 PA SPPEG‐INTRON KIT 120MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 150 RP BRAND TIER 02 PA SPPEG‐INTRON KIT 150MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 50MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 50MCG RP BRAND TIER 02 PA SPPEG‐INTRON KIT 80MCG BRAND TIER 02 PA SPPEG‐INTRON KIT 80MCG RP BRAND TIER 02 PA SPIRON PREPARATIONS ALBAFORT INJ BRAND TIER 03BIFERARX TAB BRAND TIER 03CENTRATEX CAP BRAND TIER 03CORVITA 150 TAB GENERIC TIER 01CORVITE 150 TAB Brand‐O TIER 03 PACORVITE FE TAB BRAND TIER 03DEXFERRUM INJ 50MG/ML GENERIC TIER 01 SPED CYTE F TAB GENERIC TIER 01FE C PLUS TAB GENERIC TIER 01FERAHEME INJ 510/17ML BRAND TIER 99 DEFEROCON CAP GENERIC TIER 01FEROTRIN CAP GENERIC TIER 01FEROTRINSIC CAP GENERIC TIER 01FERRALET 90 TAB BRAND TIER 03FERRAPLUS 90 TAB GENERIC TIER 01FERREX 150 CAP FORTE GENERIC TIER 01Key: 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= DrugExclusion162