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 StatusBLOOD DERIVATIVES ALBUKED 25 INJ 25% GENERIC TIER 01ALBUKED 5 INJ 5% GENERIC TIER 01ALBUMIN HUM INJ 25% GENERIC TIER 01ALBUMIN HUM INJ 5% GENERIC TIER 01ALBUMINAR‐25 INJ 25% GENERIC TIER 01ALBUMINAR‐5 INJ 5% GENERIC TIER 01ALBUMIN‐ZLB INJ GENERIC TIER 01ALBUMIN‐ZLB SOL 25% GENERIC TIER 01ALBURX INJ 5% GENERIC TIER 01ALBUTEIN INJ 25% GENERIC TIER 01ALBUTEIN INJ 5% GENERIC TIER 01BUMINATE INJ 25% GENERIC TIER 01BUMINATE INJ 5% GENERIC TIER 01FLEXBUMIN INJ 25% GENERIC TIER 01HSA DILUENT SOL STERILE GENERIC TIER 01KEDBUMIN INJ 25% GENERIC TIER 01PANHEMATIN INJ 313MG BRAND TIER 03PLASBUMIN‐25 INJ 25% GENERIC TIER 01PLASBUMIN‐5 INJ 5% GENERIC TIER 01PLASMANATE INJ 5% BRAND TIER 03BONE RESORPTION INHIBITORS ACTONEL TAB 150MG BRAND TIER 03 PAACTONEL TAB 30MG BRAND TIER 03 PAACTONEL TAB 35MG BRAND TIER 03 PAACTONEL TAB 5MG BRAND TIER 03 PAALENDRONATE TAB 10MG GENERIC TIER 01ALENDRONATE TAB 35MG GENERIC TIER 01ALENDRONATE TAB 40MG GENERIC TIER 01ALENDRONATE TAB 5MG GENERIC TIER 01ALENDRONATE TAB 70MG GENERIC TIER 01AREDIA INJ 30MG Brand‐O TIER 03 PA SPATELVIA TAB BRAND TIER 03 PABINOSTO TAB 70MG BRAND TIER 03BONIVA TAB 150MG Brand‐O TIER 03 PADIDRONEL TAB 400MG Brand‐O TIER 03 PAETIDRON DISD TAB 200MG GENERIC TIER 01ETIDRON DISD TAB 400MG GENERIC TIER 01FOSAMAX TAB 10MG Brand‐O TIER 03 PAFOSAMAX TAB 35MG Brand‐O TIER 03 PAFOSAMAX TAB 40MG Brand‐O TIER 03 PAKey: 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= DrugExclusion76