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 OXALIPLATIN INJ 100MG GENERIC TIER 01 SPOXALIPLATIN INJ 50MG GENERIC TIER 01 SPPACLITAXEL INJ 100MG GENERIC TIER 01 SPPACLITAXEL INJ 150/25ML GENERIC TIER 01 SPPACLITAXEL INJ 300/50ML GENERIC TIER 01 SPPACLITAXEL INJ 30MG/5ML GENERIC TIER 01 SPPENTOSTATIN INJ 10MG GENERIC TIER 01 SPPERJETA INJ 420/14ML BRAND TIER 03PHOTOFRIN INJ 75MG BRAND TIER 03 SPPROLEUKIN INJ 22MU BRAND TIER 02 SPPURINETHOL TAB 50MG Brand‐O TIER 03 PAREVLIMID CAP 10MG BRAND TIER 02 QL SPREVLIMID CAP 15MG BRAND TIER 02 QL SPREVLIMID CAP 2.5MG BRAND TIER 02 SPREVLIMID CAP 25MG BRAND TIER 02 QL SPREVLIMID CAP 5MG BRAND TIER 02 QL SPRHEUMATREX TAB 2.5MG BRAND TIER 03RITUXAN INJ 100MG BRAND TIER 02 PA SPRITUXAN INJ 500MG BRAND TIER 02 PA SPSOLTAMOX SOL 10MG/5ML BRAND TIER 03SPRYCEL TAB 100MG BRAND TIER 02 QL SPSPRYCEL TAB 140MG BRAND TIER 02 SPSPRYCEL TAB 20MG BRAND TIER 02 QL SPSPRYCEL TAB 50MG BRAND TIER 02 QL SPSPRYCEL TAB 70MG BRAND TIER 02 QL SPSPRYCEL TAB 80MG BRAND TIER 02 SPSTIVARGA TAB 40MG BRAND TIER 03SUPPRELIN LA KIT 50MG BRAND TIER 02 PA QL SPSUTENT CAP 12.5MG BRAND TIER 02 QL SPSUTENT CAP 25MG BRAND TIER 02 QL SPSUTENT CAP 50MG BRAND TIER 02 QL SPSYLATRON KIT 296MCG BRAND TIER 03SYLATRON KIT 444MCG BRAND TIER 03SYLATRON KIT 888MCG BRAND TIER 03TABLOID TAB 40MG BRAND TIER 02TAMOXIFEN TAB 10MG GENERIC TIER 01TAMOXIFEN TAB 20MG GENERIC TIER 01TARCEVA TAB 100MG BRAND TIER 02 QL SPTARCEVA TAB 150MG BRAND TIER 02 QL 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= DrugExclusion48