BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS SPIRA‐WASH GEL BASE BRAND TIER 99 DESTEARIC ACID MIS GENERIC TIER 99 DESTERIL WATER INJ GENERIC TIER 01STERILE DILU SOL FLOLAN BRAND TIER 03STRAWBERRY LIQ FLAVOR GENERIC TIER 99 DESWEETNESS LIQ ENHANCER BRAND TIER 99 DESYRPALTA SYP BRAND TIER 03SYRPALTA SYP CLEAR BRAND TIER 03TANGERINE OIL FLAVOR GENERIC TIER 99 DETEABERRY OIL FLAVOR GENERIC TIER 99 DETEQUILA SUNR LIQ FLAVOR GENERIC TIER 99 DETOMMY GEL GEL BRAND TIER 99 DETRAGACANTH MIS RIBBON GENERIC TIER 99 DETRANSDERMAL CRE PAIN BAS BRAND TIER 03TRANSDERMAL DIS 2" X 3" GENERIC TIER 01TROLAMINE LIQ GENERIC TIER 99 DETROLAMINE LIQ 99% GENERIC TIER 99 DETUTTI FRUTTI LIQ FLAVOR GENERIC TIER 99 DETUTTI‐FRUTTI LIQ FLAVOR GENERIC TIER 99 DEULTRADERM CRE BRAND TIER 03VANILLA LIQ FLAVOR GENERIC TIER 99 DEVANILLA EXTR LIQ FLAVOR GENERIC TIER 99 DEVANISHING CRE BRAND TIER 03VANISHING CRE BASE II GENERIC TIER 01VANISH‐PEN CRE BRAND TIER 03VERSABASE AER BRAND TIER 99 DEVERSABASE CRE BRAND TIER 99 DEVERSABASE GEL BRAND TIER 99 DEVERSABASE LIQ TRANSDML BRAND TIER 99 DEVERSABASE LOT BRAND TIER 99 DEVERSABASE SHA BRAND TIER 99 DEVERSAFREE SYP BRAND TIER 03VERSAPLUS SYP BRAND TIER 03VERSAPRO CRE BRAND TIER 03VERSAPRO GEL BRAND TIER 99 DEWATERMELON LIQ FLAVOR GENERIC TIER 99 DEWHITE WAX MIS GENERIC TIER 99 DEWILD CHERRY LIQ FLAVOR GENERIC TIER 99 DEWILEY BASIC OIN BHRT 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= DrugExclusion224
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusPHARMACEUTICAL AIDS WITEPSOL H15 MIS BASE F GENERIC TIER 99 DEZINC ACETATE CRY USP GENERIC TIER 99 DEZINC SULFATE GRA HEPTAHYR GENERIC TIER 99 DEMETER BUFFER SOL PH 4 GENERIC TIER 99 DEMETER BUFFER SOL PH 7 GENERIC TIER 99 DECOLD CRE GENERIC TIER 01EMPTY CAPSUL CAP SIZE 1 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 2 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 3 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 4 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 5 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 7 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 0 GENERIC TIER 01EMPTY CAPSUL CAP SIZE 00 GENERIC TIER 01CARAMEL LIQ COLOR GENERIC TIER 99 DEGRAPE LIQ FLAVOR GENERIC TIER 99 DEROOT BEER LIQ FLAVOR GENERIC TIER 99 DERASPBERRY LIQ FLAVOR GENERIC TIER 99 DECARAMEL LIQ FLAVOR GENERIC TIER 99 DEVANILLA LIQ BUTTERNU GENERIC TIER 99 DETROPICAL PUN LIQ FLAVOR GENERIC TIER 99 DEBEEF LIQ FLAVOR GENERIC TIER 99 DEBEEF FLAVOR LIQ GENERIC TIER 99 DEBEEF FLAVOR LIQ NATURAL GENERIC TIER 99 DEBITTER MASK LIQ FLAVOR GENERIC TIER 99 DEORA‐PLUS LIQ BRAND TIER 03ORA‐SWEET SYP BRAND TIER 03ORA‐BLEND SUS BRAND TIER 03ORA‐BLEND SF SUS BRAND TIER 03COLLODION LIQ FLEXIBLE GENERIC TIER 01CHOCOLATE CON FLAVOR GENERIC TIER 99 DEHORMONE CRE BASE GENERIC TIER 99 DEVANISHING CRE BOTANCAL BRAND TIER 03CREAM BASE CRE GENERIC TIER 01BASE CRE LIPOSOME GENERIC TIER 01POT SORBATE CRY GENERIC TIER 99 DEPLO20 BASE GEL BRAND TIER 03PLO20 BASE GEL GENERIC TIER 01CETYL ALCOHO GRA 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= DrugExclusion225
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BMC HealthNet Plan Drug List - Comm
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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