BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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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
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusANTIVIRALS, MISCELLANEOUS FOSCARNET INJ 24MG/ML GENERIC TIER 01FOSCAVIR INJ 24MG/ML BRAND TIER 03ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. AMBIEN TAB 10MG Brand‐O TIER 03 PA QLAMBIEN TAB 5MG Brand‐O TIER 03 PA QLAMBIEN CR TAB 12.5MG Brand‐O TIER 03 PA QLAMBIEN CR TAB 6.25MG Brand‐O TIER 03 PA QLBUSPIRONE TAB 10MG GENERIC TIER 01BUSPIRONE TAB 15MG GENERIC TIER 01BUSPIRONE TAB 30MG GENERIC TIER 01BUSPIRONE TAB 5MG GENERIC TIER 01BUSPIRONE TAB 7.5MG GENERIC TIER 01CHLORAL CRY HYDRATE GENERIC TIER 99 DECHLORAL HYDR SYP 500/5ML GENERIC TIER 01DROPERIDOL INJ 2.5MG/ML GENERIC TIER 01EDLUAR SUB 10MG BRAND TIER 03 PA QLEDLUAR SUB 5MG BRAND TIER 03 PA QLEQUAGESIC TAB 200‐325 BRAND TIER 03GABAZOLPIDEM PAK 5MG BRAND TIER 03HYDROXYZ HCL INJ 25MG/ML GENERIC TIER 01HYDROXYZ HCL INJ 50MG/ML GENERIC TIER 01HYDROXYZ HCL SOL 10MG/5ML GENERIC TIER 01HYDROXYZ HCL SYP 10MG/5ML GENERIC TIER 01HYDROXYZ HCL TAB 10MG GENERIC TIER 01HYDROXYZ HCL TAB 25MG GENERIC TIER 01HYDROXYZ HCL TAB 50MG GENERIC TIER 01HYDROXYZ PAM CAP 100MG GENERIC TIER 01HYDROXYZ PAM CAP 25MG GENERIC TIER 01HYDROXYZ PAM CAP 50MG GENERIC TIER 01INTERMEZZO SUB 1.75MG BRAND TIER 03 PAINTERMEZZO SUB 3.5MG BRAND TIER 03 PALUNESTA TAB 1MG BRAND TIER 03 PA QLLUNESTA TAB 2MG BRAND TIER 03 PA QLLUNESTA TAB 3MG BRAND TIER 03 PA QLMEPROBAMATE TAB 200MG GENERIC TIER 01MEPROBAMATE TAB 400MG GENERIC TIER 01PARALDEHYDE LIQ GENERIC TIER 99 DEPRECEDEX INJ 100MCG BRAND TIER 03ROZEREM TAB 8MG BRAND TIER 03SENTRAZOLPID PAK PM‐5 BRAND TIER 03Key: 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= DrugExclusion59
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BMC HealthNet Plan Drug List - Comm
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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