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 MONOJECT MIS 22GX1" BRAND TIER 03MONOJECT MIS 22GX1.5 BRAND TIER 03MONOJECT MIS CANNULA BRAND TIER 03MONOJECT MIS TIP CAPS BRAND TIER 03MONOJECT LS MIS CANN/BLN BRAND TIER 03MONOJECT LUE MIS ADAPTER BRAND TIER 03MOUTHPIECE MIS DISP LOW GENERIC TIER 01MOUTHPIECE MIS DISP UNI GENERIC TIER 01MOUTHPIECE MIS DISPOSAB GENERIC TIER 01MULTI‐DRAW MIS 20GX1" GENERIC TIER 01MULTI‐DRAW MIS 21GX1" GENERIC TIER 01MULTI‐DRAW MIS 22GX1" GENERIC TIER 01NASONEB NSL MIS REPLACEM BRAND TIER 03NASONEB NSL MIS STARTER BRAND TIER 03NEBULIZER KIT GENERIC TIER 01NEBULIZER KIT CMPRESS GENERIC TIER 01NEBULIZER KIT MASK GENERIC TIER 01NEBULIZER KIT SAMI BRAND TIER 03NEBULIZER MIS CMPRESSR BRAND TIER 03NEBULIZER MIS COMPRESS GENERIC TIER 01NEBULIZER MIS POCKET BRAND TIER 03NEBULIZER MIS ULTRASNC BRAND TIER 03NEBULIZER MIS ULTRASON GENERIC TIER 01NEEDLE MIS 18GX1" GENERIC TIER 01NEEDLE‐FREE KIT A BRAND TIER 03NEEDLE‐FREE KIT B BRAND TIER 03NEEDLE‐FREE KIT C BRAND TIER 03NORDIPEN 5 MIS DEVICE BRAND TIER 03NUTRIPORT KIT 20FR/2.5 BRAND TIER 03NUTRIPORT KIT 20FR/2.7 BRAND TIER 03NUTRIPORT KIT 20FR/3.5 BRAND TIER 03NUTRIPORT KIT 20FR/4.5 BRAND TIER 03NUTRIPORT KIT 20FR/4CM BRAND TIER 03NUTRIPORT KIT 20FR/5CM BRAND TIER 03NUTRIPORT KIT 24FR/0.8 BRAND TIER 03NUTRIPORT KIT 24FR/1.2 BRAND TIER 03NUTRIPORT KIT 24FR/1.5 BRAND TIER 03NUTRIPORT KIT 24FR/1.7 BRAND TIER 03NUTRIPORT KIT 24FR/1CM 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= DrugExclusion113