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 StatusANTITUBERCULOSIS AGENTS SEROMYCIN CAP 250MG BRAND TIER 02TRECATOR TAB 250MG BRAND TIER 03ANTITUSSIVES AIRACOF SYP GENERIC TIER 99 DEALAHIST AC LIQ 7.5‐10 BRAND TIER 99 DEALAHIST DHC LIQ 7.5‐3 BRAND TIER 99 DEALBATUSSIN CAP BRAND TIER 99 DEALBATUSSIN LIQ NN GENERIC TIER 99 DEALLFEN CD TAB 400‐10MG BRAND TIER 99 DEALLFEN CDX LIQ BRAND TIER 99 DEALLFEN CDX TAB 400‐20MG BRAND TIER 99 DEAMBIFED CD TAB BRAND TIER 99 DEAMBIFED CDX TAB BRAND TIER 99 DEAMBIFED‐G TAB CDX BRAND TIER 99 DEAMBIFED‐G CD TAB BRAND TIER 99 DEBALACALL DM SYP 5‐2‐10MG GENERIC TIER 99 DEBENZONATATE CAP 100MG GENERIC TIER 99 DEBENZONATATE CAP 200MG GENERIC TIER 99 DEBIOTUSS LIQ GENERIC TIER 99 DEBIOTUSS LIQ PEDIATRC GENERIC TIER 99 DEBROMATAN SUS PLUS GENERIC TIER 99 DEBROMFED DM SYP GENERIC TIER 99 DEBROMHIST‐DM SYP PED GENERIC TIER 99 DEBROMHIST‐PDX SYP GENERIC TIER 99 DEBRONCOPECTOL SYP BRAND TIER 99 DECARBAPHEN 12 LIQ BRAND TIER 99 DECARBAPHEN 12 SUS PED BRAND TIER 99 DECARBATUSS SYP BRAND TIER 99 DECARBATUSS‐12 SUS BRAND TIER 99 DECARBATUSS‐CL LIQ BRAND TIER 99 DECARBA‐XP LIQ BRAND TIER 99 DECENTERGY DM DRO GENERIC TIER 99 DECERON‐DM SYP GENERIC TIER 99 DECHLORDEX GP SYP GENERIC TIER 99 DECOLDEC DM SYP GENERIC TIER 99 DECORZALL LIQ 20‐30MG BRAND TIER 99 DECORZALL PLUS LIQ BRAND TIER 99 DECORZALL‐PE LIQ BRAND TIER 99 DECOTAB A TAB 4‐10MG BRAND TIER 99 DECOTAB AX TAB 4‐20MG 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= DrugExclusion54