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 YIELD NON‐AD PAD 3"X4" BRAND TIER 03ZEWA TENS MIS 502 BRAND TIER 03ZEWA TENS MIS 504 BRAND TIER 03MONOJECT MIS HOLDER BRAND TIER 03COMPRESSION MIS THIGH GENERIC TIER 01COMPRESSION MIS PANTYHSE GENERIC TIER 01TRANSMITTER MIS G4 BRAND TIER 03LITETOUCH MIS MASK SM BRAND TIER 03LITETOUCH MIS MASK MD BRAND TIER 03LITETOUCH MIS MASK LG BRAND TIER 03PROVENT MIS STARTER BRAND TIER 99 DEMINILINK RT KIT REPLACE BRAND TIER 03KANGAROO KIT 12FR/1CM BRAND TIER 03KANGAROO KIT 12FR/2CM BRAND TIER 03KANGAROO KIT 12FR/2.5 BRAND TIER 03KANGAROO KIT 12FR/2.7 BRAND TIER 03KANGAROO KIT 12FR/3CM BRAND TIER 03KANGAROO KIT 12FR/3.5 BRAND TIER 03KANGAROO KIT 12FR/4CM BRAND TIER 03KANGAROO KIT 12FR/4.5 BRAND TIER 03KANGAROO KIT 12FR/5CM BRAND TIER 03KANGAROO KIT 14FR/0.8 BRAND TIER 03KANGAROO KIT 14FR/1CM BRAND TIER 03KANGAROO KIT 14FR/1.2 BRAND TIER 03KANGAROO KIT 14FR/1.5 BRAND TIER 03KANGAROO KIT 14FR/1.7 BRAND TIER 03KANGAROO KIT 14FR/2CM BRAND TIER 03KANGAROO KIT 14FR/2.3 BRAND TIER 03KANGAROO KIT 14FR/2.5 BRAND TIER 03KANGAROO KIT 14FR/2.7 BRAND TIER 03KANGAROO KIT 14FR/3CM BRAND TIER 03KANGAROO KIT 14FR/3.5 BRAND TIER 03KANGAROO KIT 14FR/4CM BRAND TIER 03KANGAROO KIT 14FR/4.5 BRAND TIER 03KANGAROO KIT 14FR/5CM BRAND TIER 03KANGAROO KIT 16FR/0.8 BRAND TIER 03KANGAROO KIT 16FR/1CM BRAND TIER 03KANGAROO KIT 16FR/1.2 BRAND TIER 03KANGAROO KIT 16FR/1.5 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= DrugExclusion124