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 BLADE HANDLE MIS 5 GENERIC TIER 01BLADE HANDLE MIS 6 GENERIC TIER 01BLADE HANDLE MIS 7 GENERIC TIER 01BLADE HANDLE MIS 8 GENERIC TIER 01BLADE HANDLE MIS 9 GENERIC TIER 01BLUESTAR MIS BRAND TIER 99 DEBLUNT FILTER MIS CANNULA BRAND TIER 03BLUNT NEEDLE MIS 15GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 16GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 17GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 18GX1" BRAND TIER 03BLUNT NEEDLE MIS 19GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 20GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 21GX1" BRAND TIER 03BLUNT NEEDLE MIS 22GX1.5" BRAND TIER 03BLUNT NEEDLE MIS 23GX1" BRAND TIER 03BLUNTITE MIS CLIP BRAND TIER 03BOLUS FEEDIN MIS SET BRAND TIER 03BOTTLE SINGL MIS 2000ML BRAND TIER 03BREATHERITE MIS BRAND TIER 03BREATHERITE MIS LG MASK BRAND TIER 03BREATHERITE MIS MDI CHMB BRAND TIER 03BREATHERITE MIS MED MASK BRAND TIER 03BREATHERITE MIS SM MASK BRAND TIER 03BREATHERITE MIS SPACER BRAND TIER 03BREATHERITE MIS W/MASK BRAND TIER 03BURETTE SET MIS 100ML BRAND TIER 03CARTRIDGE MIS 3.15ML BRAND TIER 03CARTRIDGE MIS 3ML GENERIC TIER 01CARTRIDGE MIS IR 1000 GENERIC TIER 01CARTRIDGE MIS IR 1200 GENERIC TIER 01CARTRIDGE MIS PUMP GENERIC TIER 01CATH TRAY KIT BRAND TIER 03CATH TRAY KIT 14FR BRAND TIER 03CATH TRAY KIT 14FR‐5ML BRAND TIER 03CATH TRAY KIT 16FR‐5ML BRAND TIER 03CATH TRAY KIT 18FR‐5ML BRAND TIER 03CATH TRAY KIT UNIVERSL BRAND TIER 03CATHETER KIT INSERT 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= DrugExclusion105