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 StatusANTIMYCOBACTERIALS, MISCELLANEOUS DAPSONE TAB 25MG GENERIC TIER 01ANTINEOPLASTIC AGENTS ABRAXANE INJ 100MG BRAND TIER 03 SPADCETRIS INJ 50MG BRAND TIER 02ADRIAMYC INJ 50MG GENERIC TIER 01 SPADRIAMYCIN INJ 10MG GENERIC TIER 01 SPADRIAMYCIN INJ 20MG GENERIC TIER 01 SPADRIAMYCIN INJ 2MG/ML GENERIC TIER 01 SPADRUCIL INJ 50MG/ML GENERIC TIER 01 SPAFINITOR TAB 10MG BRAND TIER 02 QL SPAFINITOR TAB 2.5MG BRAND TIER 02 QL SPAFINITOR TAB 5MG BRAND TIER 02 QL SPAFINITOR TAB 7.5MG BRAND TIER 02 QLALFERON N INJ 5MU/ML BRAND TIER 03 SPALIMTA INJ 100MG BRAND TIER 03 SPALIMTA INJ 500MG BRAND TIER 03 SPALKERAN INJ 50MG Brand‐O TIER 03 PA SPALKERAN TAB 2MG BRAND TIER 02ANASTROZOLE TAB 1MG GENERIC TIER 01ARIMIDEX TAB 1MG Brand‐O TIER 03 PAAROMASIN TAB 25MG Brand‐O TIER 03 PAARRANON INJ 5MG/ML BRAND TIER 03 SPARZERRA CON 100/50ML BRAND TIER 03 SPARZERRA CON 100/5ML BRAND TIER 02 SPAVASTIN INJ BRAND TIER 02 SPBEXXAR CON 14MG/ML BRAND TIER 03 SPBEXXAR 131 I INJ 0.61/ML BRAND TIER 03BEXXAR 131 I INJ 5.6MCI/M BRAND TIER 03BICALUTAMIDE TAB 50MG GENERIC TIER 01BICNU INJ 100MG BRAND TIER 03 SPBLEOMYCIN INJ 15UNIT GENERIC TIER 01 SPBLEOMYCIN INJ 30UNIT GENERIC TIER 01 SPBOSULIF TAB 100MG BRAND TIER 03BOSULIF TAB 500MG BRAND TIER 03BUSULFEX INJ 6MG/ML BRAND TIER 03 SPCAMPATH INJ 30MG/ML BRAND TIER 03 SPCAMPTOSAR INJ 100/5ML Brand‐O TIER 03 PA SPCAMPTOSAR INJ 300/15ML BRAND TIER 03 SPCAMPTOSAR INJ 40MG/2ML Brand‐O TIER 03 PA SPCAPRELSA TAB 100MG 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= DrugExclusion42