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 Z‐DEX 12D TAB GENERIC TIER 99 DEZONATUSS CAP 150MG BRAND TIER 99 DEZOTEX‐12D TAB GENERIC TIER 99 DEZOTEX‐C SYP BRAND TIER 99 DEZOTEX‐D SYP BRAND TIER 99 DEZOTEX‐DM SYP BRAND TIER 99 DEZOTEX‐EX TAB BRAND TIER 99 DEZOTEX‐G SYP BRAND TIER 99 DEZ‐TUSS DM LIQ GENERIC TIER 99 DEZUTRIPRO LIQ BRAND TIER 99 DETESSALON PER CAP 100MG Brand‐O TIER 99 PA DETESSALON CAP 200MG Brand‐O TIER 99 PA DEPRO‐CLEAR CAP 200‐9MG Brand‐O TIER 99 PA DEGENTEX 30 LIQ Brand‐O TIER 99 PA DENOTUSS‐AC LIQ 2‐10MG/5 Brand‐O TIER 99 PA DESERADEX LIQ Brand‐O TIER 99 PA DEZOTEX PED DRO Brand‐O TIER 99 PA DENASOHIST DM DRO Brand‐O TIER 99 PA DETUSSIONEX SUS EXT‐REL Brand‐O TIER 99 PA DEDALLERGY DM SYP Brand‐O TIER 99 PA DESUTTAR‐SF SYP Brand‐O TIER 99 PA DESUTTAR‐2 SYP Brand‐O TIER 99 PA DEZOTEX SYP Brand‐O TIER 99 PA DEDONATUSSIN SYP DM Brand‐O TIER 99 PA DETUSSI‐12 S SUS 4‐30MG/5 Brand‐O TIER 99 PA DEATUSS DS SUS Brand‐O TIER 99 PA DECGU WC LIQ Brand‐O TIER 99 PA DETUSSI‐PRES LIQ PEDIATRC Brand‐O TIER 99 PA DEANTIULCER AGENTS & ACID SUPPRESS., MISC HELIDAC MIS BRAND TIER 03 PAPYLERA CAP BRAND TIER 02 PAANTIVIRALS (EENT) TRIFLURIDINE SOL 1% OP GENERIC TIER 01VIROPTIC SOL 1% OP Brand‐O TIER 03 PAVITRASERT IMP 4.5MG BRAND TIER 03ZIRGAN GEL 0.15% BRAND TIER 03ANTIVIRALS (SKIN & MUCOUS MEMBRANE) DENAVIR CRE 1% BRAND TIER 03LIDOVIR OIN 4‐4% BRAND TIER 03XERESE CRE 5‐1% BRAND TIER 03ZOVIRAX CRE 5% BRAND TIER 02ZOVIRAX OIN 5% BRAND TIER 02Key: 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= DrugExclusion58