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 StatusANTITUSSIVES INDAMIX DM SUS GENERIC TIER 99 DEJ‐COF DHC LIQ BRAND TIER 99 DEJ‐MAX DHC LIQ BRAND TIER 99 DELARTUS LIQ BRAND TIER 99 DEMAXIFED CD TAB BRAND TIER 99 DEMAXIFED CDX TAB BRAND TIER 99 DEMAXIFED‐G TAB CDX BRAND TIER 99 DEMAXIFED‐G CD TAB BRAND TIER 99 DEMAXIFLU CD TAB BRAND TIER 99 DEMAXIFLU CDX TAB BRAND TIER 99 DEMAXIPHEN CD TAB BRAND TIER 99 DEMAXIPHEN CDX TAB BRAND TIER 99 DEMYCI‐GC SOL 100‐10/5 GENERIC TIER 99 DEMYTUSSIN AC SYP 100‐10/5 GENERIC TIER 99 DENASOTUSS LIQ BRAND TIER 99 DENEO DM SUS BRAND TIER 99 DENEOTUSS PLUS LIQ BRAND TIER 99 DENEOTUSS‐D LIQ BRAND TIER 99 DENOHIST DMX TAB GENERIC TIER 99 DENORTUSS‐DE DRO GENERIC TIER 99 DENORTUSS‐EX LIQ 200‐20/5 GENERIC TIER 99 DENOTUSS‐PE LIQ BRAND TIER 99 DEP CHLOR DM DRO GENERIC TIER 99 DEPANATUSS DXP LIQ BRAND TIER 99 DEPEDIATEX TDM SUS BRAND TIER 99 DEPHENFLU CD TAB BRAND TIER 99 DEPHENFLU CDX TAB BRAND TIER 99 DEPOLY HIST LIQ DHC BRAND TIER 99 DEPOLY HIST NC LIQ BRAND TIER 99 DEPOLY‐TUSSIN LIQ DHC BRAND TIER 99 DEPOLY‐TUSSIN SYP EX BRAND TIER 99 DEPROHIST CD LIQ BRAND TIER 99 DEPROHIST CF LIQ BRAND TIER 99 DEPROMETH VC/ SYP CODEINE GENERIC TIER 99 DEPROMETH/COD SYP 6.25‐10 GENERIC TIER 99 DEPROMETHAZINE SYP DM GENERIC TIER 99 DEPULMARI‐GP LIQ 20‐100MG GENERIC TIER 99 DERELACON‐DM LIQ NR GENERIC TIER 99 DERELASIN DM LIQ 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= DrugExclusion56