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 SIL RT ANGLE MIS THOR CTH BRAND TIER 03SIL STR THOR MIS CATHETER BRAND TIER 03SILHOUETTE MIS 13MM BRAND TIER 03SILHOUETTE MIS 17MM BRAND TIER 03SILHOUETTE MIS 18"/13MM BRAND TIER 03SILHOUETTE MIS 23" SET BRAND TIER 03SILHOUETTE MIS 32"/17MM BRAND TIER 03SILHOUETTE MIS 43" SET BRAND TIER 03SILHOUETTE MIS COMBO BRAND TIER 03SILHOUETTE MIS FULL SET BRAND TIER 03SILICONE MSK MIS ADULT GENERIC TIER 01SILICONE MSK MIS INFANT GENERIC TIER 01SILICONE MSK MIS PED GENERIC TIER 01SINUSTAR MIS NEBULIZE BRAND TIER 03SINUSTAR MIS SYSTEM BRAND TIER 03SKIN SCRUB KIT TRAY DRY BRAND TIER 03SLEEVE COVER MIS UNIVERSA GENERIC TIER 01SMARTIP SYR MIS /CANNULA BRAND TIER 03SOF‐SENSOR MIS BRAND TIER 03SOF‐SET 24" KIT INFUSION BRAND TIER 03SOF‐SET 24" KIT MICRO QR BRAND TIER 03SOF‐SET 24" KIT ULTIM QR BRAND TIER 03SOF‐SET 42" KIT INFUSION BRAND TIER 03SOF‐SET 42" KIT MICRO QR BRAND TIER 03SOF‐SET 42" KIT ULTIM QR BRAND TIER 03SPINAL NEEDL MIS 25GX2.5" BRAND TIER 03SPIRO PD MIS BRAND TIER 03STOPCOCK MIS 1‐WAY BRAND TIER 03STOPCOCK MIS 3‐WAY BRAND TIER 03STOPCOCK MIS 4‐WAY BRAND TIER 03STOPCOCK DBL MIS 3‐WAY BRAND TIER 03STR CATHETER MIS 12FR/20" BRAND TIER 03STR CATHETER MIS 16FR/20" BRAND TIER 03STR CATHETER MIS 20FR/20" BRAND TIER 03STR CATHETER MIS 24FR/20" BRAND TIER 03STR CATHETER MIS 28FR/20" BRAND TIER 03STR CATHETER MIS 32FR/20" BRAND TIER 03STR CATHETER MIS 36FR/20" BRAND TIER 03STR CATHETER MIS 40FR/20" 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= DrugExclusion119