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 StatusDEVICES ACTIVITY PCH MIS BRAND TIER 03ADJ ONE BOTL MIS TUBING BRAND TIER 03ADULT MASK MIS GENERIC TIER 01ADULT MASK MIS LARGE GENERIC TIER 01AERCHMBR PLS MIS LRG MASK BRAND TIER 03AERCHMBR PLS MIS MASK BRAND TIER 03AERCHMBR PLS MIS SM MASK BRAND TIER 03AERCHMBR Z‐ MIS STAT PLS BRAND TIER 03AEROCHAMBER KIT ACTION BRAND TIER 03AEROCHAMBER MIS CHAMBER BRAND TIER 03AEROCHAMBER MIS FLOSIGNA BRAND TIER 03AEROCHAMBER MIS MAX/MASK BRAND TIER 03AEROCHAMBER MIS MV BRAND TIER 03AEROCHAMBER MIS PLUS BRAND TIER 03AEROECLIPSE MIS II NEB BRAND TIER 03AEROSOL MASK MIS ADULT GENERIC TIER 01AEROSOL MASK MIS PED GENERIC TIER 01AEROTRC PLUS MIS BRAND TIER 03AIR TUBE MIS /PLUGS GENERIC TIER 01AIR WATCH MIS MONITOR GENERIC TIER 01AIRIAL MIS COMPACT BRAND TIER 03AIRIAL MIS VOYAGER BRAND TIER 03AIRIAL COMP MIS COMPRESS BRAND TIER 03AIRIAL PEDIA MIS BUILDING BRAND TIER 03AIRIAL PEDIA MIS DUCK BRAND TIER 03AIRIAL PEDIA MIS FIRE ENG BRAND TIER 03AIRIAL PEDIA MIS PANDA BRAND TIER 03AIRIAL PEDIA MIS PENGUIN BRAND TIER 03AIRS DISPOSA KIT NEBULIZE BRAND TIER 03ALLERGIST KIT 0.5/26G BRAND TIER 03ALLERGIST KIT 0.5/28G BRAND TIER 03ALLERGIST KIT 1MLX26G BRAND TIER 03ALLERGIST KIT 1MLX27G BRAND TIER 03ALLERGIST KIT 1MLX28G BRAND TIER 03AMD FOAM PAD 2"X2" BRAND TIER 03AMD FOAM PAD 3.5"X3" BRAND TIER 03AMD FOAM PAD 4"X4" BRAND TIER 03AMD FOAM PAD 4"X8" BRAND TIER 03AMD FOAM PAD 6"X6" BRAND TIER 03Key: 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= DrugExclusion103