BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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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
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusIRON PREPARATIONS FERREX 150 CAP FORTE PL GENERIC TIER 01FERREX 28 TAB GENERIC TIER 01FERRIC GLUCO INJ 12.5MG/M GENERIC TIER 01FERRLECIT INJ 12.5MG/M Brand‐O TIER 03 PAFERROCITE TAB PLUS GENERIC TIER 01FERROGELS FO CAP FORTE GENERIC TIER 01FERRO‐PLEX TAB BRAND TIER 03FERROTRIN CAP BRAND TIER 03FETRIN CAP BRAND TIER 03FOLITAB TAB GENERIC TIER 01FOLIVANE‐F CAP BRAND TIER 03FOLIVANE‐PLS CAP BRAND TIER 03FOLTRIN CAP GENERIC TIER 01FUMATINIC CAP BRAND TIER 03HEMATINIC PL TAB VIT/MIN GENERIC TIER 01HEMATINIC/FA TAB GENERIC TIER 01HEMATOGEN CAP GENERIC TIER 01HEMATOGEN CAP FORTE GENERIC TIER 01HEMATOGEN FA CAP GENERIC TIER 01HEMATRON‐AF TAB Brand‐O TIER 03 PAHEMETAB TAB BRAND TIER 03HEMOCYTE TAB ‐PLUS GENERIC TIER 01HEMOCYTE PLS CAP BRAND TIER 03HEMOCYTE‐F ELX BRAND TIER 03HEMOCYTE‐F TAB GENERIC TIER 01ICAR‐C PLUS CAP SR BRAND TIER 03ICAR‐C PLUS TAB Brand‐O TIER 03 PAIFEREX 150 CAP FORTE GENERIC TIER 01INFED INJ 50MG/ML GENERIC TIER 01 SPINTEGRA F CAP BRAND TIER 03INTEGRA PLUS CAP BRAND TIER 03IROSPAN 24/6 MIS BRAND TIER 03MARTINIC CAP GENERIC TIER 01MAXARON TAB FORTE BRAND TIER 03MAXARON FORT CAP BRAND TIER 03MULTIGEN TAB GENERIC TIER 01MULTIGEN TAB FOLIC GENERIC TIER 01MULTIGEN PLS TAB GENERIC TIER 01MYFERON 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= DrugExclusion163
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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