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 EXTENDER CAP MIS 1ML/3ML BRAND TIER 03EXTENSION MIS SET BRAND TIER 03E‐Z SPACER MIS BRAND TIER 03E‐Z SPACER MIS BODY GRD BRAND TIER 03FEED/IRRIGAT MIS KIT BRAND TIER 03FEEDING SET MIS 5FR 16" BRAND TIER 03FEEDING SET MIS 8FR 16" BRAND TIER 03FEEDING TUBE MIS 10FR 42" BRAND TIER 03FEEDING TUBE MIS 10FR 43" BRAND TIER 03FEEDING TUBE MIS 10FR 55" BRAND TIER 03FEEDING TUBE MIS 12FR 43" BRAND TIER 03FEEDING TUBE MIS 12FR 55" BRAND TIER 03FEEDING TUBE MIS 12FR 60" BRAND TIER 03FEEDING TUBE MIS 3.5FR12" BRAND TIER 03FEEDING TUBE MIS 5FR 20" BRAND TIER 03FEEDING TUBE MIS 5FR 36" BRAND TIER 03FEEDING TUBE MIS 6.5FR16" BRAND TIER 03FEEDING TUBE MIS 6.5FR20" BRAND TIER 03FEEDING TUBE MIS 6.5FR36" BRAND TIER 03FEEDING TUBE MIS 6FR 20" BRAND TIER 03FEEDING TUBE MIS 6FR 36" BRAND TIER 03FEEDING TUBE MIS 8FR 16" BRAND TIER 03FEEDING TUBE MIS 8FR 20" BRAND TIER 03FEEDING TUBE MIS 8FR 42" BRAND TIER 03FEEDING TUBE MIS 8FR 43" BRAND TIER 03FEEDING TUBE MIS 8FR 55" BRAND TIER 03FEEDING TUBE MIS 9FR 35" BRAND TIER 03FEEDING TUBE MIS 9FR/16FR BRAND TIER 03FEEDING TUBE MIS SYSTEM BRAND TIER 03FERGUSN CATH MIS 28FR BRAND TIER 03FERGUSN CATH MIS 32FR BRAND TIER 03FERGUSN CATH MIS 36FR BRAND TIER 03FILTER AIR MIS PP GENERIC TIER 01FILTER ASPIR MIS 18GX3" BRAND TIER 03FILTER CONN MIS 5 MICRON BRAND TIER 03FILTER NEEDL MIS 18GX1" BRAND TIER 03FILTER NEEDL MIS 20GX1.5" BRAND TIER 03FINGER GRIP MIS EXTENDER BRAND TIER 03FLEXI‐SEAL MIS FMS 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= DrugExclusion108