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 SUMP DRAIN MIS 16FR/12" BRAND TIER 03SUMP DRAIN MIS 20FR/12" BRAND TIER 03SUMP DRAIN MIS 20FR/20" BRAND TIER 03SUMP DRAIN MIS 24FR/20" BRAND TIER 03SUMP DRAIN MIS 28FR/12" BRAND TIER 03SUMP DRAIN MIS 28FR/20" BRAND TIER 03SUPPOSISTRIP MIS 1.4GM BRAND TIER 03SUPPOSISTRIP MIS 1.9GM GENERIC TIER 01SUPPOSITORY MIS 1.46GM GENERIC TIER 01SUPPOSITORY MIS 2.25GM GENERIC TIER 01SURE‐T MIS 23"/6MM BRAND TIER 03SURE‐T MIS 23"/8MM BRAND TIER 03SURE‐T INFUS MIS SET 18" BRAND TIER 03SURE‐T INFUS MIS SET 23" BRAND TIER 03SURE‐T INFUS MIS SET 32" BRAND TIER 03SURG BLADES MIS SIZE 10A BRAND TIER 03SURG BLADES MIS SIZE 12 BRAND TIER 03SURG BLADES MIS SIZE 12 GENERIC TIER 01SURG BLADES MIS SIZE 12B BRAND TIER 03SURG BLADES MIS SIZE 15C BRAND TIER 03SURG BLADES MIS SIZE 23 BRAND TIER 03SURG BLADES MIS SIZE 23 GENERIC TIER 01SURG BLADES MIS SIZE 24 BRAND TIER 03SURG BLADES MIS SIZE 24 GENERIC TIER 01SURG BLADES MIS SIZE 25 BRAND TIER 03SURG BLADES MIS SIZE 25 GENERIC TIER 01SURG BLADES MIS SIZE 60 BRAND TIER 03SURGUARD2 MIS 18GX1" BRAND TIER 03SURGUARD2 MIS 18GX1.5" BRAND TIER 03SURGUARD2 MIS 19GX1" BRAND TIER 03SURGUARD2 MIS 19GX1.5" BRAND TIER 03SURGUARD2 MIS 20GX1" BRAND TIER 03SURGUARD2 MIS 20GX1.5" BRAND TIER 03SURGUARD2 MIS 21GX1" BRAND TIER 03SURGUARD2 MIS 21GX1.5" BRAND TIER 03SURGUARD2 MIS 22GX1" BRAND TIER 03SURGUARD2 MIS 22GX1.5" BRAND TIER 03SURGUARD2 MIS 23GX1" BRAND TIER 03SURGUARD2 MIS 23GX1.5" 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= DrugExclusion120