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 CATHETER MIS 14FR‐5ML BRAND TIER 03CATHETER MIS 16FR‐5ML BRAND TIER 03CATHETER MIS 30FR‐30 BRAND TIER 03CGMS MIS SOFTWARE BRAND TIER 03CGMS CABLE MIS BRAND TIER 03CGMS SYSTEM MIS GOLD BRAND TIER 03CHEMOSAFETY KIT SPILL BRAND TIER 03CLINICAL PRD MIS PUMP ADP BRAND TIER 03CO MONITOR KIT GENERIC TIER 01CO MONITOR MIS GENERIC TIER 01CO MONITOR MIS T PIECES GENERIC TIER 01COMFORT SET MIS 23"/17MM BRAND TIER 03COMFORT SET MIS 31"/17MM BRAND TIER 03COMFORT SET MIS 43"/17MM BRAND TIER 03COMFORT SHRT MIS 23"/13MM BRAND TIER 03COMFORT SHRT MIS 31"/13MM BRAND TIER 03COMFORT SHRT MIS 43"/13MM BRAND TIER 03COMP AIR MIS COMP/NEB BRAND TIER 03COMP AIR MIS ELITE BRAND TIER 03CONCEPTION KIT GENERIC TIER 99 DECONFIRM NOW MIS DETECTOR BRAND TIER 03CONNECT TUBE MIS 3/16"X6' BRAND TIER 03CONNECTOR MIS LUER LOC BRAND TIER 03CONNECTOR MIS Y‐SITE BRAND TIER 03CONTINUOUS MIS FEED SET BRAND TIER 03CONVERSION MIS BABY SZ1 BRAND TIER 03CONVERSION MIS BABY SZ2 BRAND TIER 03CONVERSION MIS BABY SZ3 BRAND TIER 03CURAFOAM PAD 4"X5" BRAND TIER 03CURAFOAM PAD 6"X8" BRAND TIER 03CURI‐STRIP MIS 1/2"X4" BRAND TIER 03CURI‐STRIP MIS 1/4"X1.5 BRAND TIER 03CURI‐STRIP MIS 1/4"X3" BRAND TIER 03CURI‐STRIP MIS 1/4"X4" BRAND TIER 03CURI‐STRIP MIS 1/8"X3" BRAND TIER 03CURITY AMD PAD 2"X2" BRAND TIER 03CURITY AMD PAD 4"X4" BRAND TIER 03CURITY CATH KIT 14FRENCH BRAND TIER 03CURITY FOLEY KIT 16FR‐5ML 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= DrugExclusion106