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

ALIMTA INJ 500MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP
ALINIA SUS 100MG/5M ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 2
ALINIA TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 2
ALKERAN INJ 50MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP
ALKERAN TAB 2MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2
ALLERGIST KIT 0.5/26G DEVICES BRAND Excluded TIER 99
ALLERGIST KIT 0.5/28G DEVICES BRAND Excluded TIER 99
ALLERGIST KIT 1MLX26G DEVICES BRAND Excluded TIER 99
ALLERGIST KIT 1MLX27G DEVICES BRAND Excluded TIER 99
ALLERGIST KIT 1MLX28G DEVICES BRAND Excluded TIER 99
ALLERSCRIPT MIS TABLETS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99
ALLERX MIS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99
ALLERX DF MIS PROPYLAMINE DERIVATIVES Brand‐O PA TIER 3
ALLERX DF 30 MIS PROPYLAMINE DERIVATIVES Brand‐O PA TIER 3
ALLERX PE MIS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99
ALLERX‐D TAB 120/2.5
ALPHA‐ AND BETA‐ADRENERGIC
AGONISTS Brand‐O PA TIER 99
ALLFEN CD TAB 400‐10MG ANTITUSSIVES BRAND Excluded TIER 99
ALLFEN CDX LIQ ANTITUSSIVES BRAND Excluded TIER 99
ALLFEN CDX TAB 400‐20MG ANTITUSSIVES BRAND Excluded TIER 99
ALLOPURINOL INJ 500MG ANTIGOUT AGENTS GENERIC Covered TIER 1
ALLOPURINOL TAB 100MG ANTIGOUT AGENTS GENERIC Covered TIER 1
ALLOPURINOL TAB 300MG ANTIGOUT AGENTS GENERIC Covered TIER 1
ALMOND OIL LIQ BITTER PHARMACEUTICAL AIDS GENERIC Excluded TIER 99
ALOCRIL SOL 2% ANTIALLERGIC AGENTS BRAND Covered TIER 3
ALODOX KIT 20MG TETRACYCLINES BRAND Covered TIER 3
ALOMIDE SOL 0.1% OP ANTIALLERGIC AGENTS BRAND Covered TIER 3
ALOPRIM INJ 500MG ANTIGOUT AGENTS Brand‐O PA 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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