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 UNGUATOR 4MM MIS VARIONOZ BRAND TIER 03UNGUATOR AIR MIS 300/390 BRAND TIER 03UNGUATOR AIR MIS 500/600 BRAND TIER 03UNGUATOR JAR MIS 100/140 BRAND TIER 03UNGUATOR JAR MIS 200/280 BRAND TIER 03UNGUATOR JAR MIS 30/42 BRAND TIER 03UNGUATOR JAR MIS 300/390 BRAND TIER 03UNGUATOR JAR MIS 50/70 BRAND TIER 03UNGUATOR JAR MIS 500/600 BRAND TIER 03UNGUTOR 50 MIS 43MM BRAND TIER 03UNIVERSAL MIS PUMP ADP BRAND TIER 03URETHR CATH MIS 14FRENCH BRAND TIER 03URINE METER MIS KIDS BRAND TIER 03VAGINAL APPL MIS SUPPOSIT GENERIC TIER 01VALVD HOLDNG MIS CHAMBER BRAND TIER 03V‐GO 20 KIT BRAND TIER 02V‐GO 30 KIT BRAND TIER 02V‐GO 40 KIT BRAND TIER 02VIOS MIS SYSTEM BRAND TIER 03VIOS LC MIS SPRINT BRAND TIER 03VIOS LC PLUS MIS BRAND TIER 03VIOS LC PLUS MIS DELUXE BRAND TIER 03VIOS LC PLUS MIS PEDIATRC BRAND TIER 03VIXONE DISP MIS NEBULIZR BRAND TIER 03VORTEX VALVE MIS CHAMBER BRAND TIER 03VORTEX/MASK MIS CHILDS BRAND TIER 03VORTEX/MASK MIS TODDLER BRAND TIER 03WATCHHALER MIS BRAND TIER 03WINDMILL MIS TRAINER BRAND TIER 03XEROFORM MIS DRESSING BRAND TIER 03XEROFORM MIS OVERWRAP BRAND TIER 03XEROFORM PET MIS OVERWRAP BRAND TIER 03XEROFORM PET MIS ROLL BRAND TIER 03XEROFORM PET PAD 1"X8" BRAND TIER 03XEROFORM PET PAD 2"X2" BRAND TIER 03XEROFORM PET PAD 4"X4" BRAND TIER 03XEROFORM PET PAD 5"X9" BRAND TIER 03XROFORM PET MIS OVERWRAP BRAND TIER 03YIELD NON‐AD PAD 2"X3" 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= DrugExclusion123