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 INFUSION SET MIS 42" 9MM GENERIC TIER 01INFUSION SET MIS 43" BRAND TIER 03INFUSION SET MIS 43" GENERIC TIER 01INFUSION SET MIS 43" 10MM GENERIC TIER 01INFUSION SET MIS 43" 6MM BRAND TIER 03INFUSION SET MIS 43" 8MM BRAND TIER 03INFUSION SET MIS 43" 9MM BRAND TIER 03INFUSION SET MIS 43"/COMF GENERIC TIER 01INFUSION SET MIS 43"COMFO GENERIC TIER 01INFUSION SET MIS CATH 23" GENERIC TIER 01INFUSION SET MIS CATH 31" GENERIC TIER 01INFUSION SET MIS CATH 43" GENERIC TIER 01INJECTOR MIS LUER LOC BRAND TIER 03INJECTOR CAP MIS PHASEAL BRAND TIER 03INSERTION KIT 16FRENCH BRAND TIER 03INSERTION KIT 18FRENCH BRAND TIER 03INSPIRATION MIS ELITE BRAND TIER 03INSPIRATION MIS NEBULIZR BRAND TIER 03INSPIREASE MIS DD SYST BRAND TIER 03INSUFLON MIS 25GX0.71 BRAND TIER 03INSULIN PUMP KIT IR2020 GENERIC TIER 99 DEINSULIN PUMP MIS AMIGO BRAND TIER 03INSULIN PUMP MIS PEDIATRI BRAND TIER 03INSULIN PUMP MIS PROGRAM BRAND TIER 03INSYTE AUTOG MIS 14GX1.75 BRAND TIER 03INSYTE AUTOG MIS 18GX1.16 BRAND TIER 03INSYTE AUTOG MIS 22GX1" BRAND TIER 03INSYTE AUTOG MIS 24GX3/4" BRAND TIER 03INTERMITTENT MIS 14FR40CM BRAND TIER 03INTRO NEEDLE MIS 18GX1.25 BRAND TIER 03I‐PORT MIS 6MM BRAND TIER 03I‐PORT MIS 9MM BRAND TIER 03IRRIGAT SYRG MIS 50ML BUL BRAND TIER 03IV BAG HANGR MIS PHASEAL BRAND TIER 03J‐TIP KIT KIT ADAPTERS BRAND TIER 03KANG EXTENSN MIS Y‐SITE BRAND TIER 03KANGAROO KIT 12FR/0.8 BRAND TIER 03KANGAROO KIT 12FR/1.2 BRAND TIER 03KANGAROO KIT 12FR/1.5 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= DrugExclusion111