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 EPIDUR NEEDL MIS 20GX3.5" BRAND TIER 0312ML SYRINGE MIS 21GX1.5" BRAND TIER 031ML TB SYRNG MIS 26GX3/8" BRAND TIER 033ML LL SYRNG MIS 21GX1.5" BRAND TIER 036ML LL SYRNG MIS 21GX1.5" BRAND TIER 031ML SYRINGE MIS 23GX1" BRAND TIER 033ML SYRINGE MIS 21GX1.5" BRAND TIER 031ML TB SYRNG MIS 27GX1/2" BRAND TIER 03INSULIN SYRG MIS 1ML/27G BRAND TIER 033ML LL SYRNG MIS 22GX1" BRAND TIER 035ML SYRINGE MIS 22GX1" BRAND TIER 033ML LL SYRNG MIS 22GX1.25 BRAND TIER 0360ML SYRINGE MIS LUER LOK BRAND TIER 0360ML SYRINGE MIS CATH TIP BRAND TIER 031ML TB SYRNG MIS 28GX1/2" BRAND TIER 0312ML SYRINGE MIS 22GX1.5" BRAND TIER 033ML LL SYRNG MIS 22GX1.5" BRAND TIER 036ML LL SYRNG MIS 22GX1.5" BRAND TIER 031ML SYRINGE MIS 25GX5/8" BRAND TIER 033ML SYRINGE MIS 22GX1.5" BRAND TIER 035ML SYRINGE MIS 22GX1.5" BRAND TIER 033ML LL SYRNG MIS 23GX1" BRAND TIER 033ML SYRINGE MIS 23GX1" BRAND TIER 033ML SYRINGE MIS 23GX1.5" BRAND TIER 031ML SYRINGE MIS 26GX3/8" BRAND TIER 03INSULIN SYRG MIS 1ML/28G BRAND TIER 033ML LL SYRNG MIS 25GX5/8" BRAND TIER 033ML SYRINGE MIS 25GX5/8" BRAND TIER 033ML LL SYRNG MIS 25GX1" BRAND TIER 033ML SYRINGE MIS 25GX1" BRAND TIER 03INSULIN SYRG MIS 1ML/29G BRAND TIER 03INSULIN SYRG MIS 1ML/30G BRAND TIER 033ML LL SYRNG MIS 27GX1.25 BRAND TIER 03TRACHEOSTOMY KIT CARE BRAND TIER 03NEBULIZER KIT MASK PED GENERIC TIER 011ML ALLERGIS KIT TRAY SYR BRAND TIER 03DIAGNOSTIC AGENTS ABLAVAR INJ 244MG/ML BRAND TIER 99 DEASPERGILLUS INJ 1:500 GENERIC TIER 99 DECERETEC INJ BRAND TIER 99 DEKey: 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= DrugExclusion129