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 RESPERAL‐DM DRO 12‐1‐5MG GENERIC TIER 99 DEREZIRA SOL 60‐5/5ML BRAND TIER 99 DEROBAFEN AC SYP 100‐10/5 GENERIC TIER 99 DEROMILAR AC SOL 100‐10/5 GENERIC TIER 99 DERU‐TUSS DM SYP GENERIC TIER 99 DERYNATUSS TAB BRAND TIER 99 DESUDATEX‐DM TAB GENERIC TIER 99 DESUTAN‐DM SUS GENERIC TIER 99 DETANNIHIST‐12 SUS 4‐30MG/5 GENERIC TIER 99 DETGQ 15DM/5PE SYP H/2CPM GENERIC TIER 99 DETGQ 30/ SYP 150/15 GENERIC TIER 99 DETGQ 30/PSE/3 SYP BRM/15DM GENERIC TIER 99 DETGQ 50PSE/3 SYP BRM/30DM GENERIC TIER 99 DETGQ 7.5PEH/4 LIQ BRM/15DM GENERIC TIER 99 DETL‐DEX DM LIQ GENERIC TIER 99 DETL‐HIST CD LIQ GENERIC TIER 99 DETL‐HIST CM LIQ GENERIC TIER 99 DETREXBROM LIQ GENERIC TIER 99 DETRISPEC DMX DRO PEDIATRC BRAND TIER 99 DETRISPEC DMX LIQ BRAND TIER 99 DETRISPEC PSE DRO PEDIATRC BRAND TIER 99 DETRISPEC PSE LIQ BRAND TIER 99 DETRITUSS SYP BRAND TIER 99 DETUSNEL PED‐C SYP BRAND TIER 99 DETUSSAFED EX LIQ GENERIC TIER 99 DETUSSI‐12 TAB 5‐60MG BRAND TIER 99 DETUSSI‐12D TAB 10‐40‐60 BRAND TIER 99 DETUSSI‐12D S SUS BRAND TIER 99 DETUSSICAPS CAP 10‐8MG BRAND TIER 99 DETUSSICAPS CAP 5‐4MG BRAND TIER 99 DETUSSIGON TAB 5MG GENERIC TIER 99 DETUSSO‐C LIQ 200‐10MG BRAND TIER 99 DETUSSO‐DMR CAP 7‐14‐288 BRAND TIER 99 DETUSSO‐ZMR CAP 8‐200MG BRAND TIER 99 DETUSSO‐ZR SYP 7.5‐150 BRAND TIER 99 DEVAZOTAN SUS BRAND TIER 99 DEV‐COF SUS GENERIC TIER 99 DEZ‐COF I SUS BRAND TIER 99 DEZ‐DEX SYP 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= DrugExclusion57