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 DELTEC COZMO MIS INL PUMP BRAND TIER 03DENTAL NEEDL MIS 25GX21MM GENERIC TIER 01DENTAL NEEDL MIS 25GX32MM GENERIC TIER 01DENTAL NEEDL MIS 27GX21MM GENERIC TIER 01DENTAL NEEDL MIS 27GX32MM GENERIC TIER 01DENTAL NEEDL MIS 30GX12MM GENERIC TIER 01DENTAL NEEDL MIS 30GX21MM GENERIC TIER 01DENTAL NEEDL MIS 30GX32MM GENERIC TIER 01DISPENSER MIS MEGAPUMP BRAND TIER 03DOVER TRAY KIT 14FR‐5ML BRAND TIER 03DOVER TRAY KIT 16FR‐5ML BRAND TIER 03DOVER TRAY KIT 18FR‐5ML BRAND TIER 03DOVER URETH MIS 10FR BRAND TIER 03DRAINAGE BAG MIS BRAND TIER 03DRAINAGE BAG MIS 2000ML BRAND TIER 03DRIHEP PLUS KIT 100UNIT BRAND TIER 03DRIHEP SYRNG KIT 100UNIT BRAND TIER 03DUAL THORACI MIS DRAIN BRAND TIER 03DURASAF MINI KIT SPIN/EPI BRAND TIER 03DURASAFE SET KIT SPIN/EPI BRAND TIER 03EARPOPPER MIS MID EAR GENERIC TIER 01EASIVENT MIS BRAND TIER 03EASIVENT MIS MASK LG BRAND TIER 03EASIVENT MIS MASK SM BRAND TIER 03EASIVENT MIS MASK MED BRAND TIER 03ECLIPSE NDL MIS 21GX1" BRAND TIER 03EFLOW SCF MIS AEROSOL BRAND TIER 03EFLOW SCF MIS NEBULIZR BRAND TIER 03ELITE DC AUT MIS ADAPTER BRAND TIER 03ELITE SYSTEM MIS NEBULIZR BRAND TIER 03EMJOI TENS MIS BRAND TIER 03ENTENSION ST MIS 4 FOOT BRAND TIER 03ENTERAL PUMP MIS JOEY BRAND TIER 03EPIDUR NEEDL MIS 18GX2.5" BRAND TIER 03EPIDURAL KIT 17GX3.5" BRAND TIER 03EPIDURAL KIT 18GX3.5" BRAND TIER 03ERECAID KIT CLASSIC BRAND TIER 99 DEERECAID KIT ESTEEM BRAND TIER 99 DEEROS‐CTD MIS BRAND TIER 99 DEKey: 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= DrugExclusion107