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 AMD FOAM PAD 8"X8" BRAND TIER 03ANESTH NEEDL MIS 23X1‐3/8 GENERIC TIER 01ANGEL WING MIS 19GX3/4" BRAND TIER 03ANGEL WING MIS 21GX3/4" BRAND TIER 03ANGEL WING MIS 23GX3/4" BRAND TIER 03ANGEL WING MIS 25GX3/4" BRAND TIER 03ANGEL WING MIS TRANSFER BRAND TIER 03ANGEL WING MIS TUBE HLD BRAND TIER 03AQUA‐SEAL MIS UNIT BRAND TIER 03ARGYLE PLUG MIS INFUSION BRAND TIER 03ASSEMBLY MIS FIXTURE BRAND TIER 03ASTHMA CNTRL KIT GENERIC TIER 01ASTHMAPACK KIT II BRAND TIER 03ASTHMAPACK KIT III BRAND TIER 03ASTHMAPACK I KIT BRAND TIER 03AUTOSHIELD MIS 30GX3/16 BRAND TIER 03AUTOTRANSFUS MIS ACC UNT BRAND TIER 03AVOSTARTGRIP MIS BRAND TIER 03BARD URETHR MIS CATH 16" BRAND TIER 03BD ECLIPSE MIS 18GX1.5" BRAND TIER 03BD ECLIPSE MIS 22GX1" BRAND TIER 03BD ECLIPSE MIS 23GX1" BRAND TIER 03BD FIL NEED MIS 5 MICRON GENERIC TIER 01BD NEXIVA MIS 18GX1.25 BRAND TIER 03BD NEXIVA MIS 18GX1.75 BRAND TIER 03BD NEXIVA MIS 20GX1" BRAND TIER 03BD NEXIVA MIS 20GX1.25 BRAND TIER 03BD NEXIVA MIS 20GX1.75 BRAND TIER 03BD NEXIVA MIS 22GX1" BRAND TIER 03BD NEXIVA MIS 24GX0.56 BRAND TIER 03BD NEXIVA MIS 24GX0.75 BRAND TIER 03BD SAF‐T‐INT KIT 22GX0.75 BRAND TIER 03BD SAF‐T‐INT KIT 24GX0.75 BRAND TIER 03BLADE HANDLE MIS 3L GENERIC TIER 01BLADE HANDLE MIS 3LA GENERIC TIER 01BLADE HANDLE MIS 3S BRAND TIER 03BLADE HANDLE MIS 4 GENERIC TIER 01BLADE HANDLE MIS 4L GENERIC TIER 01BLADE HANDLE MIS 4S 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= DrugExclusion104