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 SAFTY NEEDLE MIS 18GX1" BRAND TIER 03SAFTY NEEDLE MIS 18GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 19GX1" BRAND TIER 03SAFTY NEEDLE MIS 19GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 20GX1" BRAND TIER 03SAFTY NEEDLE MIS 20GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 21GX1" BRAND TIER 03SAFTY NEEDLE MIS 21GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 21GX5/8" BRAND TIER 03SAFTY NEEDLE MIS 22GX1" BRAND TIER 03SAFTY NEEDLE MIS 22GX1.5" BRAND TIER 03SAFTY NEEDLE MIS 23GX1" BRAND TIER 03SAFTY NEEDLE MIS 23GX5/8" BRAND TIER 03SAFTY NEEDLE MIS 25GX1" BRAND TIER 03SAFTY NEEDLE MIS 25GX5/8" BRAND TIER 03SALEM SUMP MIS 10FR BRAND TIER 03SALEM SUMP MIS 12FR BRAND TIER 03SALEM SUMP MIS 14FR BRAND TIER 03SALEM SUMP MIS 16FR BRAND TIER 03SALEM SUMP MIS 18FR BRAND TIER 03SCALPEL/BLAD MIS SIZE 12 BRAND TIER 03SCALPEL/BLAD MIS SIZE 12 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 12B GENERIC TIER 01SCALPEL/BLAD MIS SIZE 20 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 21 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 23 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 25T GENERIC TIER 01SECONDARY MIS SET/DRIP BRAND TIER 03SEVEN PLUS KIT STARTER BRAND TIER 03SEVEN PLUS MIS RECEIVER BRAND TIER 03SEVEN PLUS MIS TRANSMIT BRAND TIER 03SEVEN SYSTEM MIS SENSOR BRAND TIER 03SHARPS CONT MIS 1.1QT BRAND TIER 03SHARPS CONT MIS 4QT BRAND TIER 03SIDESTREAM KIT NEBULIZE BRAND TIER 03SIDESTREAM MIS MASK BRAND TIER 03SIDESTREAM MIS NEBULIZR BRAND TIER 03SIDESTREAM MIS PLUS BRAND TIER 03SIL MEDIASTN MIS CATHETER 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= DrugExclusion118