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 StatusANTINEOPLASTIC AGENTS FEMARA TAB 2.5MG Brand‐O TIER 03 PAFIRMAGON INJ 120MG BRAND TIER 02FIRMAGON INJ 120MG GENERIC TIER 01 PA SPFIRMAGON INJ 80MG BRAND TIER 02FIRMAGON INJ 80MG GENERIC TIER 01 PA SPFLOXURIDINE INJ 0.5GM GENERIC TIER 01 SPFLUDARA INJ 50MG Brand‐O TIER 03 PA SPFLUDARABINE INJ 50MG GENERIC TIER 01 SPFLUDARABINE INJ 50MG/2ML GENERIC TIER 01 SPFLUOROURACIL INJ 1GM/20ML GENERIC TIER 01 SPFLUOROURACIL INJ 2.5G/50M GENERIC TIER 01 SPFLUOROURACIL INJ 500MG/10 GENERIC TIER 01 SPFLUOROURACIL INJ 50MG/ML GENERIC TIER 01 SPFLUOROURACIL INJ 5GM/100M GENERIC TIER 01 SPFLUTAMIDE CAP 125MG GENERIC TIER 01FOLOTYN INJ 20MG/ML BRAND TIER 02FOLOTYN INJ 40MG/2ML BRAND TIER 02GEMCITABINE INJ 1GM GENERIC TIER 01GEMCITABINE INJ 1GM SPGEMCITABINE INJ 200MG GENERIC TIER 01GEMCITABINE INJ 200MG SPGEMCITABINE INJ 2GM GENERIC TIER 01GEMZAR INJ 1GM Brand‐O TIER 03 PA SPGEMZAR INJ 200MG Brand‐O TIER 03 PA SPGLEEVEC TAB 100MG BRAND TIER 02 QL SPGLEEVEC TAB 400MG BRAND TIER 02 QL SPGLIADEL WAF 7.7MG BRAND TIER 03HALAVEN INJ 1MG/2ML BRAND TIER 02HERCEPTIN INJ 440MG BRAND TIER 02 SPHEXALEN CAP 50MG BRAND TIER 02HYCAMTIN CAP 0.25MG BRAND TIER 02 SPHYCAMTIN CAP 1MG BRAND TIER 02 SPHYCAMTIN INJ 4MG Brand‐O TIER 03 PA SPHYDREA CAP 500MG Brand‐O TIER 03 PAHYDROXYUREA CAP 500MG GENERIC TIER 01IDAMYCIN PFS INJ 10/10ML Brand‐O TIER 03 PA SPIDAMYCIN PFS INJ 20/20ML Brand‐O TIER 03 PA SPIDAMYCIN PFS INJ 5MG/5ML Brand‐O TIER 03 PA SPIDARUBICIN INJ 10/10ML GENERIC TIER 01 SPKey: 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= DrugExclusion45