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 KANGAROO KIT 16FR/1.7 BRAND TIER 03KANGAROO KIT 16FR/2CM BRAND TIER 03KANGAROO KIT 16FR/2.3 BRAND TIER 03KANGAROO KIT 16FR/2.7 BRAND TIER 03KANGAROO KIT 16FR/3CM BRAND TIER 03KANGAROO KIT 16FR/3.5 BRAND TIER 03KANGAROO KIT 16FR/4CM BRAND TIER 03KANGAROO KIT 16FR/4.5 BRAND TIER 03KANGAROO KIT 16FR/5CM BRAND TIER 03KANGAROO KIT 18FR/2CM BRAND TIER 03KANGAROO KIT 18FR/2.3 BRAND TIER 03KANGAROO KIT 18FR/2.5 BRAND TIER 03KANGAROO KIT 18FR/2.7 BRAND TIER 03KANGAROO KIT 18FR/3CM BRAND TIER 03KANGAROO KIT 18FR/3.5 BRAND TIER 03KANGAROO KIT 18FR/4CM BRAND TIER 03KANGAROO KIT 18FR/4.5 BRAND TIER 03KANGAROO KIT 18FR/5CM BRAND TIER 03KANGAROO KIT 20FR/0.8 BRAND TIER 03KANGAROO KIT 20FR/1CM BRAND TIER 03KANGAROO KIT 20FR/1.2 BRAND TIER 03KANGAROO KIT 20FR/1.5 BRAND TIER 03KANGAROO KIT 20FR/1.7 BRAND TIER 03KANGAROO KIT 20FR/2CM BRAND TIER 03KANGAROO KIT 20FR/2.3 BRAND TIER 03G4 PLATINUM KIT RECEIVER BRAND TIER 03G4 SENSOR KIT BRAND TIER 03CURITY COMB MIS PREP RZR BRAND TIER 03SPECIMEN MIS CONATINR BRAND TIER 03THIGH LENGTH MIS SM/REG BRAND TIER 03THIGH LENGTH MIS MED/LONG BRAND TIER 03SPONGE COUNT MIS BAGS BRAND TIER 03GRAVITY SET MIS 1000ML BRAND TIER 03FEEDING TUBE MIS 14FR 36" BRAND TIER 03FEEDING TUBE MIS 10FR 36" BRAND TIER 03GASTROS TUBE MIS 22FRENCH BRAND TIER 03GASTROS TUBE MIS 26FRENCH BRAND TIER 03FEEDING TUBE MIS 8FR 36" BRAND TIER 03FEEDING TUBE MIS 12FR 36" 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= DrugExclusion125