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 SURGUARD2 MIS 25GX1.5" BRAND TIER 03SURGUARD2 MIS 25GX5/8" BRAND TIER 03SURGUARD2 MIS 26GX1/2" BRAND TIER 03SURGUARD2 MIS 27GX1/2" BRAND TIER 03SURGUARD2 MIS 30GX1/2" BRAND TIER 03SYRINGE FILT MIS 25MM BRAND TIER 03SYRINGE TRAY MIS PHASEAL BRAND TIER 03SYRNG BARREL MIS 1.5OZ GENERIC TIER 01SYRNG BARREL MIS 1OZ GENERIC TIER 01SYRNG BARREL MIS 2OZ GENERIC TIER 01SYRNG BARREL MIS 3OZ GENERIC TIER 01SYRNG BARREL MIS 4OZ GENERIC TIER 01T.E.D. MIS LG/LONG BRAND TIER 03T.E.D. MIS LG/REG BRAND TIER 03T.E.D. MIS LG/SHORT BRAND TIER 03T.E.D. MIS MD/SHORT BRAND TIER 03T.E.D. MIS MED/LONG BRAND TIER 03T.E.D. MIS MED/REG BRAND TIER 03T.E.D. MIS MED‐LONG BRAND TIER 03T.E.D. MIS SM/LONG BRAND TIER 03T.E.D. MIS SM/REG BRAND TIER 03T.E.D. MIS SM/SHORT BRAND TIER 03T.E.D. MIS XL/LONG BRAND TIER 03T.E.D. MIS XL/REG BRAND TIER 03T.E.D. MIS XSM/LONG BRAND TIER 03T.E.D. MIS X‐SM/REG BRAND TIER 03TB SYRINGE MIS 0.5/28G BRAND TIER 03TENDER 1 KIT 31" BRAND TIER 03TENDER 1 KIT 43" BRAND TIER 03TENDER 1 KIT INFUSION BRAND TIER 03TENDER 2 KIT 24" BRAND TIER 03TENDER 2 KIT 31" BRAND TIER 03TEXAS CATH MIS MALE BRAND TIER 03THI AORTIC MIS CANNULA BRAND TIER 03THINSET MIS 23"/6MM BRAND TIER 03THINSET MIS 23"/9MM BRAND TIER 03THINSET MIS 43"/6MM BRAND TIER 03THINSET MIS 43"/9MM BRAND TIER 03THINSET SYR MIS RES 1.8 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= DrugExclusion121