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 StatusROENTGENOGRAPHY GLOFIL‐125 INJ 0.1% BRAND TIER 03ISOVUE‐200 INJ 41% BRAND TIER 03ISOVUE‐250 INJ 51% BRAND TIER 03ISOVUE‐250 INJ 51%MLTPK BRAND TIER 03ISOVUE‐300 INJ 61% BRAND TIER 03ISOVUE‐300 INJ 61%MLTPK BRAND TIER 03ISOVUE‐370 INJ 76% BRAND TIER 03ISOVUE‐370 INJ 76%MLTPK BRAND TIER 03ISOVUE‐M 200 INJ 41% BRAND TIER 03ISOVUE‐M 300 INJ 61% BRAND TIER 03MAXIBAR SUS 210% BRAND TIER 03MD‐76 R INJ BRAND TIER 03MD‐GASTROVIE SOL 66‐10% GENERIC TIER 01MULTIHANCE SOL BRAND TIER 03OMNIPAQUE INJ 180MG/ML BRAND TIER 03OMNIPAQUE INJ 240MG/ML BRAND TIER 03OMNIPAQUE INJ 300MG/ML BRAND TIER 03OMNIPAQUE INJ 350MG/ML BRAND TIER 03OPTIRAY 160 INJ 34% BRAND TIER 03OPTIRAY 240 INJ 51% BRAND TIER 03OPTIRAY 300 INJ 64% BRAND TIER 03OPTIRAY 320 INJ 68% BRAND TIER 03OPTIRAY 350 INJ 74% BRAND TIER 03POLIBAR SUS 100% BRAND TIER 03POLIBAR ACB KIT 96% BRAND TIER 03POLIBAR PLUS SUS 105% BRAND TIER 99 DEREADI‐CAT SUS 1.3% BRAND TIER 03READI‐CAT 2 SUS 2.1% BRAND TIER 03READI‐CAT 2 SUS APPLE BRAND TIER 03READI‐CAT 2 SUS BANANA BRAND TIER 03READI‐CAT 2 SUS BERRY BRAND TIER 03READI‐CAT 2 SUS MOCHACCI BRAND TIER 03READI‐CAT 2 SUS VANILLA BRAND TIER 03SINOGRAFIN INJ BRAND TIER 03SITZMARKS CAP BRAND TIER 03TAGITOL V SUS 40% BRAND TIER 03ULTRAVIST INJ 150MG/ML BRAND TIER 03ULTRAVIST INJ 240MG/ML BRAND TIER 03ULTRAVIST INJ 300MG/ML BRAND TIER 03Key: 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= DrugExclusion244