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 StatusPHARMACEUTICAL AIDS FOOD COLOR LIQ PINK GENERIC TIER 99 DEFOOD COLOR LIQ RED GENERIC TIER 99 DEFOOD COLOR LIQ WHITE GENERIC TIER 99 DEFOOD COLOR LIQ YELLOW GENERIC TIER 99 DEGELATIN EMPT CAP LOCKING GENERIC TIER 01GRAPEFRUIT OIL FLAVOR GENERIC TIER 99 DEGUAVA FLAVOR LIQ GENERIC TIER 99 DEGUMMY TROCHE GEL GELATIN GENERIC TIER 99 DEHAM FLAVOR LIQ GENERIC TIER 99 DEHONEY FLAVOR LIQ GENERIC TIER 99 DEHOREHOUND LIQ FLAVOR GENERIC TIER 99 DEHRT BASE CRE GENERIC TIER 99 DEHRT BASE CRE BOTANICA GENERIC TIER 99 DEHRT BASE CRE HEAVY GENERIC TIER 99 DEHRT BASE CRE SUPREME BRAND TIER 99 DEHRT BASE CRE WOMEN GENERIC TIER 99 DEHRT BASE GEL FOR MEN GENERIC TIER 99 DEHRT NATURAL CRE BASE GENERIC TIER 99 DEHRT NATURAL LOT BASE GENERIC TIER 99 DEHYDROGEL GEL BRAND TIER 03IRON OXIDE PST BLACK GENERIC TIER 99 DEIRON OXIDE PST RED GENERIC TIER 99 DEIRON OXIDE PST YELLOW GENERIC TIER 99 DEKAHLUA LIQ FLAVOR GENERIC TIER 99 DEKRIS‐ESTER LIQ 236 GENERIC TIER 99 DEKRISGEL 100 GEL BRAND TIER 03LECITHIN GEL GENERIC TIER 01LEMON LIQ FLAVOR GENERIC TIER 99 DELEMON EXTRAC LIQ GENERIC TIER 99 DELEMON FLAVOR OIL GENERIC TIER 99 DELEMONADE OIL FLAVOR GENERIC TIER 99 DEL‐HISTIDINE CRY MONOHYDR GENERIC TIER 99 DELICORICE LIQ FLAVOR GENERIC TIER 99 DELIME FLAVOR OIL GENERIC TIER 99 DELIPO CREAM CRE BASE BRAND TIER 03LIPOBASE CRE HEAVY GENERIC TIER 01LIPOBASE CRE REGULAR GENERIC TIER 01LIPODERM HMW GEL PCCA BRAND TIER 99 DELIPOPEN CRE 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= DrugExclusion221