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 GASTROS TUBE MIS 24FRENCH BRAND TIER 03PUMP SET MIS 1000ML BRAND TIER 03PUMP SET MIS 1200ML BRAND TIER 03PUMP SET MIS 600ML BRAND TIER 03AMIELLE VAG MIS TRAINER BRAND TIER 03BD SAFETY‐LO MIS SET BRAND TIER 03PUMP SET MIS SPIKE BRAND TIER 03PULMO‐AIDE MIS COMP/NEB BRAND TIER 03DEVILBISS MIS NEBULIZR BRAND TIER 03NEBULIZER MIS GENERIC TIER 01COMPRESSION MIS STOCKING GENERIC TIER 01COMPRESSION MIS SOCKS GENERIC TIER 01SUPPOSITORY MIS MOLD GENERIC TIER 01INSPIREASE MIS RES BAG BRAND TIER 03 QLINSPIREASE MIS BAGS BRAND TIER 03 QLINSPIREASE MIS MOUTHPCE BRAND TIER 03 QLINSPIREASE MIS REP MOUT BRAND TIER 03 QLURINE METER MIS BRAND TIER 03ROBINSN CATH MIS 8FR BRAND TIER 03SHARPS CONT MIS 14QT BRAND TIER 03SHARPS CONT MIS 8QT BRAND TIER 03KENGUARD MIS IRRIGATN BRAND TIER 03KANGAROO MIS IRRIGAT BRAND TIER 03STOMA MEASUR MIS DEVICE BRAND TIER 03SURG BLADES MIS SIZE 10 BRAND TIER 03SURG BLADES MIS SIZE 10 GENERIC TIER 01SURG BLADES MIS SIZE 20 BRAND TIER 03SURG BLADES MIS SIZE 20 GENERIC TIER 01SURG BLADES MIS SIZE 21 BRAND TIER 03SURG BLADES MIS SIZE 21 GENERIC TIER 01SURG BLADES MIS SIZE 22 BRAND TIER 03SURG BLADES MIS SIZE 22 GENERIC TIER 01SURG BLADES MIS SIZE 11 BRAND TIER 03SURG BLADES MIS SIZE 11 GENERIC TIER 01SURG BLADES MIS SIZE 15 BRAND TIER 03SURG BLADES MIS SIZE 15 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 10 BRAND TIER 03SCALPEL/BLAD MIS SIZE 10 GENERIC TIER 01SCALPEL/BLAD MIS SIZE 11 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= DrugExclusion126