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 PCCA SYRUP SYP VEHICLE BRAND TIER 03PCCA VANISH CRE BASE BRAND TIER 03PCCA VANISHI CRE LIGHT BRAND TIER 03PCCA VANPEN CRE BASE BRAND TIER 03PCCA‐PLUS SUS BRAND TIER 03PEACH FLAVOR LIQ GENERIC TIER 99 DEPEANUT BUTTR LIQ FLAVOR GENERIC TIER 99 DEPEG OIN BASE L GENERIC TIER 01PENCREAM CRE BRAND TIER 03PENDERM CRE BRAND TIER 03PEPPERMINT OIL FLAVOR GENERIC TIER 99 DEPHARMABASE CRE COSMETIC BRAND TIER 03PHARMABASE CRE HEAVY BRAND TIER 03PINA COLADA LIQ FLAVOR GENERIC TIER 99 DEPINEAPPLE LIQ FLAVOR GENERIC TIER 99 DEPIZZA FLAVOR LIQ GENERIC TIER 99 DEPLACEBO #00 CAP GENERIC TIER 01PLO GEL MEDIFLO GENERIC TIER 01PLO MEDIFLO KIT KIT BRAND TIER 99 DEPLO TRANSDER CRE BRAND TIER 03PLURONIC GEL F127 20% BRAND TIER 99 DEPLURONIC GEL F127 30% BRAND TIER 99 DEPOLYGLYCOL MIS TROCHE BRAND TIER 99 DEPOLYPEG OIN BASE BRAND TIER 03POT PERMANGT CRY GENERIC TIER 99 DEPOTASSIUM GRA SORBATE GENERIC TIER 99 DEPRACAMAC OIL BASE BRAND TIER 99 DEPRACASIL TM‐ CRE PLUS BRAND TIER 03PRALINES/CRM LIQ FLAVOR GENERIC TIER 99 DEPUMPKIN LIQ FLAVOR GENERIC TIER 99 DERASPBERRY CON FLAVOR GENERIC TIER 99 DESALT STABLE CRE BRAND TIER 03SARSAPARILLA LIQ FLAVOR GENERIC TIER 99 DESEPINEO P600 LIQ BRAND TIER 99 DESHRIMP LIQ FLAVOR GENERIC TIER 99 DESIMPLE SYP GENERIC TIER 01SIMPLGEL 30 GEL BRAND TIER 99 DESOD CITRATE CRY GENERIC TIER 99 DESPEARMINT OIL FLAVOR GENERIC 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= DrugExclusion223