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 TARCEVA TAB 25MG BRAND TIER 02 QL SPTARGRETIN CAP 75MG BRAND TIER 03 SPTASIGNA CAP 150MG BRAND TIER 02 QL SPTASIGNA CAP 200MG BRAND TIER 02 QL SPTAXOTERE INJ 20/0.5ML BRAND TIER 03 SPTAXOTERE INJ 20MG/ML BRAND TIER 03 SPTAXOTERE INJ 80MG/2ML BRAND TIER 03 SPTAXOTERE INJ 80MG/4ML BRAND TIER 03 SPTEMODAR CAP 100MG BRAND TIER 02 SPTEMODAR CAP 140MG BRAND TIER 02 SPTEMODAR CAP 180MG BRAND TIER 02 SPTEMODAR CAP 20MG BRAND TIER 02 SPTEMODAR CAP 250MG BRAND TIER 02 SPTEMODAR CAP 5MG BRAND TIER 02 SPTEMODAR INJ 100MG BRAND TIER 03 SPTHIOTEPA INJ 15MG GENERIC TIER 01 SPTOPOSAR INJ 100/5ML GENERIC TIER 01 SPTOPOSAR INJ 1GM/50ML GENERIC TIER 01 SPTOPOSAR INJ 500/25ML GENERIC TIER 01 SPTOPOTECAN INJ 4MG GENERIC TIER 01 SPTOPOTECAN INJ 4MG/4ML GENERIC TIER 01 SPTORISEL SOL 25MG/ML BRAND TIER 02 SPTREANDA INJ 100MG BRAND TIER 02 SPTREANDA INJ 25MG BRAND TIER 02 SPTRELSTAR DEP INJ 3.75MG BRAND TIER 03 PA SPTRELSTAR LA INJ 11.25MG BRAND TIER 03 PA SPTRELSTAR MIX INJ 22.5MG BRAND TIER 03 PA SPTRETINOIN CAP 10MG GENERIC TIER 01TREXALL TAB 10MG BRAND TIER 02TREXALL TAB 15MG BRAND TIER 02TREXALL TAB 5MG BRAND TIER 02TREXALL TAB 7.5MG BRAND TIER 02TRISENOX SOL 10MG/10M BRAND TIER 03 SPTYKERB TAB 250MG BRAND TIER 02 QL SPVALSTAR SOL 40MG/ML BRAND TIER 03 SPVANDETANIB TAB 100MG GENERIC TIER 01VANDETANIB TAB 300MG GENERIC TIER 01VANTAS KIT 50MG BRAND TIER 02 PA SPVECTIBIX INJ 100MG BRAND TIER 03 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= DrugExclusion49