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

AGGRASTAT INJ 25MG/500 PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 3
AGGRENOX CAP 25‐200MG PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 2
AGRIFLU INJ 2010‐11 VACCINES BRAND Covered TIER 3
AGRYLIN CAP 0.5MG PLATELET‐REDUCING AGENTS Brand‐O PA TIER 3
AHIST TAB 12MG PROPYLAMINE DERIVATIVES BRAND Covered TIER 3
A‐HYDROCORT INJ 100MG ADRENALS GENERIC Covered TIER 1
AIR TUBE MIS /PLUGS DEVICES GENERIC Excluded TIER 99
AIR WATCH MIS MONITOR DEVICES GENERIC Excluded TIER 99
AIRACOF SYP ANTITUSSIVES GENERIC Covered TIER 1
AIRAVITE TAB VITAMIN B COMPLEX GENERIC Covered TIER 1
AIRIAL MIS COMPACT DEVICES BRAND Excluded TIER 99
AIRIAL MIS VOYAGER DEVICES BRAND Excluded TIER 99
AIRIAL COMP MIS COMPRESS DEVICES BRAND Excluded TIER 99
AIRIAL PEDIA MIS BUILDING DEVICES BRAND Excluded TIER 99
AIRIAL PEDIA MIS DUCK DEVICES BRAND Excluded TIER 99
AIRIAL PEDIA MIS FIRE ENG DEVICES BRAND Excluded TIER 99
AIRIAL PEDIA MIS PANDA DEVICES BRAND Excluded TIER 99
AIRIAL PEDIA MIS PENGUIN DEVICES BRAND Excluded TIER 99
AIRS DISPOSA KIT NEBULIZE DEVICES BRAND Excluded TIER 99
AK‐CON SOL 0.1% OP VASOCONSTRICTORS GENERIC Covered TIER 1
AK‐FLUOR INJ 10% OP OCULAR DISORDERS GENERIC Covered TIER 1
AKNE‐MYCIN OIN 2%
ANTIBACTERIALS (SKIN & MUCOUS
MEMBRANE) BRAND Covered TIER 3
AKORN BALANC SOL SALT OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1
AK‐PENTOLATE SOL 1% OP MYDRIATICS GENERIC Covered TIER 1
AK‐POLY‐BAC OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1
AKTEN GEL 3.5% LOCAL ANESTHETICS (EENT) BRAND Covered TIER 3
Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization Required, SP= Restricted to specialty pharmacy, QL= Quantity Limit,
MO= Mail order eligible after one prescription fill at retail
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