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 StatusPROKINETIC AGENTS METOZOLV ODT TAB 10MG BRAND TIER 03 PA QLMETOZOLV ODT TAB 5MG BRAND TIER 03 PA QLREGLAN INJ 5MG/ML Brand‐O TIER 03 PAREGLAN TAB 10MG Brand‐O TIER 03 PAREGLAN TAB 5MG Brand‐O TIER 03 PAPROPYLAMINE DERIVATIVES AEROHIST TAB 8‐2.5MG BRAND TIER 03AEROKID SYP BRAND TIER 99 DEAHIST TAB 12MG BRAND TIER 03ALA‐HIST TAB 6‐25MG BRAND TIER 03ALA‐HIST D TAB 6‐25‐20 BRAND TIER 99 DEALENAZE‐D LIQ GENERIC TIER 99 DEALENAZE‐D NR LIQ GENERIC TIER 99 DEALLERSCRIPT MIS TABLETS BRAND TIER 99 DEALLERX MIS BRAND TIER 99 DEALLERX DF MIS Brand‐O TIER 03 PAALLERX DF 30 MIS Brand‐O TIER 03 PAALLERX PE MIS BRAND TIER 99 DEBIDHIST‐D TAB 6‐45MG GENERIC TIER 99 DEBPM TAB 6MG GENERIC TIER 01BPM PSEUDO TAB 6‐45MG GENERIC TIER 99 DEBROMAX TAB 11MG GENERIC TIER 01BROMPHENIRAM CHW 12MG GENERIC TIER 01BROMSPIRO LIQ 2MG/5ML GENERIC TIER 01CENHIST CHW 6‐15MG BRAND TIER 99 DECENTERGY DRO 1‐2MG/ML GENERIC TIER 99 DECHLOR‐MES D SYP LIQUID GENERIC TIER 99 DECHLOR‐MES JR CAP 4‐20MG GENERIC TIER 99 DEC‐TAN D PLUS SUS BRAND TIER 99 DEDALLERGY CHW BRAND TIER 99 DEDALLERGY SYP BRAND TIER 99 DEDALLERGY TAB BRAND TIER 99 DEDALLERGY TAB ER BRAND TIER 99 DEDALLERGY PE SYP BRAND TIER 99 DEDALLERGY PE TAB GENERIC TIER 99 DEDALLERGY PSE TAB BRAND TIER 99 DEDALLERGY‐JR SUS BRAND TIER 99 DEDECON‐A ELX 2‐5MG/5M BRAND TIER 99 DEDEHISTINE SYP GENERIC TIER 99 DEDEXCHLORPHEN SYP 2MG/5ML GENERIC TIER 01Key: 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= DrugExclusion231