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

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ALPRAZOLAM TAB 0.5MG OD BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 1MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 1MG ER BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 1MG ODT BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 2MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 2MG ER BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 2MG ODT BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB 3MG ER BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB XR 0.5MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB XR 1MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB XR 2MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPRAZOLAM TAB XR 3MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 ALPROSTADIL INJ 500MCG VASODILATING AGENTS, MISCELLANEOUS GENERIC Covered TIER 1 ALREX SUS 0.2% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 ALSUMA INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL ALTABAX OIN 1% ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) 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 16
ALTACAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 ALTACE CAP 1.25MG ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS Brand‐O PA TIER 3 ALTACE CAP 10MG ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS Brand‐O PA TIER 3 ALTACE CAP 2.5MG ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS Brand‐O PA TIER 3 ALTACE CAP 5MG ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS Brand‐O PA TIER 3 ALTAFLUOR SOL 0.25‐0.4 OCULAR DISORDERS GENERIC Covered TIER 1 ALTAFRIN SOL 10% OP VASOCONSTRICTORS GENERIC Covered TIER 1 ALTAFRIN SOL 2.5% OP VASOCONSTRICTORS GENERIC Covered TIER 1 ALTAVERA TAB CONTRACEPTIVES GENERIC Covered TIER 1 ALTOPREV TAB 20MG ER HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 ALTOPREV TAB 40MG ER HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 ALTOPREV TAB 60MG ER HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 ALUMINUM SOL ACETATE ASTRINGENTS GENERIC Covered TIER 1 ALUMINUM CL CRY ASTRINGENTS GENERIC Excluded TIER 99 ALUMINUM CL CRY HEXAHYDR ASTRINGENTS GENERIC Excluded TIER 99 ALUVEA CRE 39% KERATOLYTIC AGENTS Brand‐O PA TIER 3 ALVESCO AER 160MCG ADRENALS BRAND Covered TIER 2 ALVESCO AER 80MCG ADRENALS BRAND Covered TIER 2 ALYACEN TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 ALYACEN TAB 7/7/7 CONTRACEPTIVES GENERIC Covered TIER 1 ALZ‐NAC TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 AMANTADINE CAP 100MG ADAMANTANES (CNS) GENERIC Covered TIER 1 AMANTADINE SYP 50MG/5ML ADAMANTANES (CNS) GENERIC Covered TIER 1 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 17
Page 1 and 2: BMC HealthNet Plan Drug List - Empl
Page 3 and 4: ACCURETIC TAB 20‐25MG ANGIOTENSIN
Page 5 and 6: ACTIQ LOZ 400MCG OPIATE AGONISTS Br
Page 7 and 8: ADDERALL XR CAP 5MG AMPHETAMINES Br
Page 9 and 10: AERCHMBR PLS MIS LRG MASK DEVICES B
Page 11 and 12: ALA CORT CRE 1% ANTI‐INFLAMMATORY
Page 13 and 14: ALCORTIN A GEL LOCAL ANTI‐INFECTI
Page 15: ALOQUIN GEL 1.25‐1% ANTIFULGALS(S
Page 19 and 20: AMERGE TAB 2.5MG SELECTIVE SEROTONI
Page 21 and 22: AMITRIPTYLIN TAB 100MG TRYCYCLICS &
Page 23 and 24: AMOXICILLIN CAP 500MG AMINOPENICILL
Page 25 and 26: ANABAR TAB ANALGESICS AND ANTIPYRET
Page 27 and 28: ANGELIQ TAB 0.5‐1MG ESTROGENS BRA
Page 29 and 30: APOKYN INJ 10MG/ML NONERGOT‐DERIV
Page 31 and 32: ARGATROBAN INJ 100MG/ML DIRECT THRO
Page 33 and 34: ASMALPRED SOL 15MG/5ML ADRENALS GEN
Page 35 and 36: ATIVAN TAB 2MG ATOPICLAIR CRE BENZO
Page 37 and 38: AUG BETAMET CRE 0.05% ANTI‐INFLAM
Page 39 and 40: AVC CRE 15% LOCAL ANTI‐INFECTIVES
Page 41 and 42: AZITHROMYCIN TAB 250MG OTHER MACROL
Page 43 and 44: BARD URETHR MIS CATH 16" DEVICES BR
Page 45 and 46: BENEFIX INJ 3000UNIT HEMOSTATICS BR
Page 47 and 48: BENZONATATE CAP 200MG ANTITUSSIVES
Page 49 and 50: BETAPACE TAB 160MG BETA‐ADRENERGI
Page 51 and 52: BIONECT GEL 0.2% SKIN AND MUCOUS ME
Page 53 and 54: BONE MARROW KIT BIOPSY LOCAL ANESTH
Page 55 and 56: BREATHERITE MIS W/MASK DEVICES BRAN
Page 57 and 58: BUMETANIDE INJ 0.25/ML LOOP DIURETI
Page 59 and 60: BUSPIRONE TAB 7.5MG ANXIOLYTICS, SE
Page 61 and 62: CAFCIT SOL 60MG/3ML CAFERGOT TAB 1
Page 63 and 64: CALDOLOR INJ 800/8ML OTHER NONSTERO
Page 65 and 66: CAPTOPRIL TAB 50MG ANGIOTENSIN‐CO
Page 67 and 68:
CARBOGEL GEL 940 PHARMACEUTICAL AID
Page 69 and 70:
CARDURA XL TAB 8MG ALPHA‐ADRENERG
Page 71 and 72:
CATAPRES‐TTS DIS 0.1/24HR CENTRAL
Page 73 and 74:
CEFAZOL/DEX SOL 1GM CEFAZOL/DEX SOL
Page 75 and 76:
CEFPROZIL SUS 250/5ML CEFPROZIL TAB
Page 77 and 78:
CEFUROXIME SUS 125/5ML SECOND GENER
Page 79 and 80:
CEPROTIN INJ 500 UNIT ANTICOAGULANT
Page 81 and 82:
CHLORAL HYDR SYP 500/5ML ANXIOLYTIC
Page 83 and 84:
CIALIS TAB 10MG CIALIS TAB 2.5MG CI
Page 85 and 86:
CIPROFLOXACN TAB 500MG QUINOLONES G
Page 87 and 88:
CLARITHROMYC SUS 125/5ML OTHER MACR
Page 89 and 90:
CLINDAMYCIN CAP 75MG LINCOMYCINS GE
Page 91 and 92:
CLOBETASOL LOT 0.05% ANTI‐INFLAMM
Page 93 and 94:
CLORAZ DIPOT TAB 15MG BENZODIAZEPIN
Page 95 and 96:
COLAZAL CAP 750MG ANTI‐INFLAMMATO
Page 97 and 98:
CONCERTA TAB 18MG ANOREX.,RESPIR.,C
Page 99 and 100:
COREG CR CAP 80MG BETA‐ADRENERGIC
Page 101 and 102:
COSOPT PF SOL CARBONIC ANHYDRASE IN
Page 103 and 104:
CROMOLYN SOD SOL 4% OP ANTIALLERGIC
Page 105 and 106:
CURI‐STRIP MIS 1/2"X4" DEVICES BR
Page 107 and 108:
CYCLOPHOSPH INJ 2GM ANTINEOPLASTIC
Page 109 and 110:
D10W/NACL INJ 0.9% REPLACEMENT PREP
Page 111 and 112:
DAYTRANA DIS 10MG/9HR ANOREX.,RESPI
Page 113 and 114:
DENAVIR CRE 1% ANTIVIRALS (SKIN & M
Page 115 and 116:
DERMATOP OIN 0.1% ANTI‐INFLAMMATO
Page 117 and 118:
DESOXIMETAS OIN 0.05% ANTI‐INFLAM
Page 119 and 120:
DEXTROSE INJ 2.5% CALORIC AGENTS GE
Page 121 and 122:
DIBENZYLINE CAP 10MG DICLOFEN POT T
Page 123 and 124:
DIFLUCAN TAB 150MG AZOLES Brand‐O
Page 125 and 126:
DILTIAZEM CAP 180MG/24 DILTIAZEM CA
Page 127 and 128:
DIOVAN TAB 160MG ANGIOTENSIN II REC
Page 129 and 130:
DIURIL SUS 250/5ML THIAZIDE DIURETI
Page 131 and 132:
DONEPEZIL TAB 5MG PARASYMPATHOMIMET
Page 133 and 134:
DOXEPIN HCL CAP 25MG TRYCYCLICS & O
Page 135 and 136:
DUEXIS TAB 800‐26.6 OTHER NONSTER
Page 137 and 138:
E.E.S. 400 TAB 400MG ERYTHROMYCINS
Page 139 and 140:
EEMT TAB ESTROGENS GENERIC Excluded
Page 141 and 142:
ELOCON OIN 0.1% ANTI‐INFLAMMATORY
Page 143 and 144:
ENBREL SRCLK INJ 50MG/ML DISEASE‐
Page 145 and 146:
EPIFLUR CHW 0.5MG F CARIOSTATIC AGE
Page 147 and 148:
EQUAGESIC TAB 200‐325 ANXIOLYTICS
Page 149 and 150:
ESCITALOPRAM TAB 10MG SELECTIVE‐S
Page 151 and 152:
ETHOSUXIMIDE CAP 250MG SUCCINIMIDES
Page 153 and 154:
EVOXAC CAP 30MG PARASYMPATHOMIMETIC
Page 155 and 156:
E‐Z‐CAT DRY PAK ROENTGENOGRAPHY
Page 157 and 158:
FEEDING TUBE MIS 8FR 16" DEVICES BR
Page 159 and 160:
FENTANYL DIS 100MCG/H OPIATE AGONIS
Page 161 and 162:
FINACEA GEL 15% SKIN AND MUCOUS MEM
Page 163 and 164:
FLOLAN INJ 0.5MG VASODILATING AGENT
Page 165 and 166:
FLUOCIN ACET OIN 0.025% ANTI‐INFL
Page 167 and 168:
FLUOXETINE CAP 10MG SELECTIVE‐SER
Page 169 and 170:
FLUVOXAMINE TAB 25MG SELECTIVE‐SE
Page 171 and 172:
FOLEY TRAY KIT 5ML DEVICES BRAND Ex
Page 173 and 174:
FORTICAL SPR 200/ACT PARATHYROID GE
Page 175 and 176:
FUZEON INJ 90MG HIV ENTRY AND FUSIO
Page 177 and 178:
GALANTAMINE TAB 4MG PARASYMPATHOMIM
Page 179 and 180:
GELCLAIR GEL SKIN AND MUCOUS MEMBRA
Page 181 and 182:
GENTAMICIN OIN 0.1% ANTIBACTERIALS
Page 183 and 184:
GLUCOTROL TAB 5MG SULFONYLUREAS Bra
Page 185 and 186:
GRAFIX PRIME MIS 7.5X15CM OTHER MIS
Page 187 and 188:
HALONATE PAC KIT ANTI‐INFLAMMATOR
Page 189 and 190:
HELIXATE FS SOL 250UNIT HEMOSTATICS
Page 191 and 192:
HISTOACRYL LIQ DEVICES BRAND Exclud
Page 193 and 194:
HUMIRA PEN KIT CROHNS DISEASE‐MOD
Page 195 and 196:
HYDROCORT LOT 2.5% ANTI‐INFLAMMAT
Page 197 and 198:
HYDROXYZ HCL TAB 50MG ANXIOLYTICS,
Page 199 and 200:
HYPERTENIPIN PAK 2.5MG DIHYDROPYRID
Page 201 and 202:
IFOSFAMIDE KIT MESNA ANTINEOPLASTIC
Page 203 and 204:
INDIUM IN111 INJ OXYQUINO DIAGNOSTI
Page 205 and 206:
INFUSION SET MIS CATH 23" DEVICES G
Page 207 and 208:
INTERCED TC7 PAD 1.5"X2" SKIN AND M
Page 209 and 210:
IPRATROPIUM SPR 0.03% ANTIMUSCARINI
Page 211 and 212:
ISOPTIN SR TAB 240MG CALCIUM‐CHAN
Page 213 and 214:
JANUMET TAB 50‐1000 DIPEPTIDYL PE
Page 215 and 216:
KADIAN CAP 40MG CR OPIATE AGONISTS
Page 217 and 218:
KANGAROO KIT 18FR/3.5 DEVICES BRAND
Page 219 and 220:
KEPPRA TAB 1000MG ANTICONVULSANTS,
Page 221 and 222:
KETOROLAC INJ 15MG/ML OTHER NONSTER
Page 223 and 224:
K‐PHOS TAB MF ACIDIFYING AGENTS B
Page 225 and 226:
LAMICTAL ODT TAB 100MG ANTICONVULSA
Page 227 and 228:
LANTUS INJ SOLOSTAR INSULINS BRAND
Page 229 and 230:
LEUCOVOR CA TAB 25MG ANTIDOTES GENE
Page 231 and 232:
LEVITRA TAB 20MG PHOSPHODIESTERASE
Page 233 and 234:
LEVOTHYROXIN TAB 300MCG THYROID AGE
Page 235 and 236:
LIDOCAIN/D5W INJ 4MG/ML CLASS IB AN
Page 237 and 238:
LIORESAL INT INJ 0.05MG/1 GABA‐DE
Page 239 and 240:
LITEAIRE MIS DEVICES BRAND Excluded
Page 241 and 242:
LOHIST‐12 TAB 12 HOUR PROPYLAMINE
Page 243 and 244:
LOTEMAX OIN 0.5% CORTICOSTEROIDS (E
Page 245 and 246:
LTA 360 KIT SOL 4% LOCAL ANESTHETIC
Page 247 and 248:
L‐VALINE CRY CALORIC AGENTS GENER
Page 249 and 250:
MALARONE TAB 250‐100 ANTIMALARIAL
Page 251 and 252:
MAVIK TAB 4MG ANGIOTENSIN‐CONVERT
Page 253 and 254:
MEFOXIN INJ 2GM/50ML CEPHAMYCINS BR
Page 255 and 256:
MERREM INJ 500MG CARBAPENEMS Brand
Page 257 and 258:
METHADOSE TAB 10MG OPIATE AGONISTS
Page 259 and 260:
METHYLIN TAB 20MG METHYLIN TAB 20MG
Page 261 and 262:
METIPRANOLOL SOL 0.3% BETA‐ADRENE
Page 263 and 264:
METRONIDAZOL LOT 0.75% ANTIBACTERIA
Page 265 and 266:
MIDAZOLAM INJ 1MG/ML BENZODIAZEPINE
Page 267 and 268:
MINOCYCLINE CAP 50MG TETRACYCLINES
Page 269 and 270:
MIRTAZAPINE TAB 45MG ODT ANTIDEPRES
Page 271 and 272:
MONODOX CAP 100MG TETRACYCLINES Bra
Page 273 and 274:
MORPHINE SUL TAB 200MG ER OPIATE AG
Page 275 and 276:
MUSE SUP 1000MCG VASODILATING AGENT
Page 277 and 278:
MYSOLINE TAB 50MG BARBITURATES (ANT
Page 279 and 280:
NAMENDA TAB 5MG NAPRELAN PAK NAPREL
Page 281 and 282:
NASOTUSS LIQ ANTITUSSIVES BRAND Exc
Page 283 and 284:
NEFAZODONE TAB 250MG SEROTONIN MODU
Page 285 and 286:
NEPHRONEX TAB 1MG MULTIVITAMIN PREP
Page 287 and 288:
NEVIRAPINE TAB 200MG NONNUCLEOSIDE
Page 289 and 290:
NIRAVAM TAB 0.5MG BENZODIAZEPINES (
Page 291 and 292:
NOHIST DMX TAB ANTITUSSIVES GENERIC
Page 293 and 294:
NORTRIPTYLIN CAP 25MG TRYCYCLICS &
Page 295 and 296:
NUOX GEL 6‐3% SKIN AND MUCOUS MEM
Page 297 and 298:
NYSTATIN POW 1BU POLYENES GENERIC E
Page 299 and 300:
OFFICE SAFET KIT 3.2QT DEVICES BRAN
Page 301 and 302:
OMNITROPE 5 MIS DEVICE DEVICES BRAN
Page 303 and 304:
OPTIRAY 160 INJ 34% ROENTGENOGRAPHY
Page 305 and 306:
ORTHO COIL DPR KIT 50 CONTRACEPTIVE
Page 307 and 308:
OTIC CARE DRO LOCAL ANESTHETICS (EE
Page 309 and 310:
OXYBUTYNIN TAB 15MG ER GENITOURINAR
Page 311 and 312:
PACNEX MX LIQ 4.25% LOCAL ANTI‐IN
Page 313 and 314:
PARAFON FORT TAB DSC CENTRALLY ACTI
Page 315 and 316:
PATROL PUMP MIS 40MM CAP DEVICES BR
Page 317 and 318:
PEDIPIROX‐4 KIT NAIL HYDROXYPYRID
Page 319 and 320:
PENTOTHAL INJ 500MG BARBITURATES (G
Page 321 and 322:
PEXEVA TAB 30MG SELECTIVE‐SEROTON
Page 323 and 324:
PHENOBARB TAB 100MG PHENOBARB TAB 1
Page 325 and 326:
PHYSOS SALIC INJ 1MG/ML PARASYMPATH
Page 327 and 328:
PLASMANATE INJ 5% BLOOD DERIVATIVES
Page 329 and 330:
POLYETHYLENE LIQ GLYCOL CATHARTICS
Page 331 and 332:
POT CITRATE TAB 540MG ALKALINIZING
Page 333 and 334:
PRAMOSONE OIN 1% ANTI‐INFLAMMATOR
Page 335 and 336:
PREDNISOLONE SUS 1% OP CORTICOSTERO
Page 337 and 338:
PRENATE MINI CAP MULTIVITAMIN PREPA
Page 339 and 340:
PRIMLEV TAB 7.5‐300 OPIATE AGONIS
Page 341 and 342:
PROCTOCREAM CRE HC 2.5% ANTI‐INFL
Page 343 and 344:
PROMETHAZINE TAB 25MG PHENOTHIAZINE
Page 345 and 346:
PROQUAD INJ VACCINES BRAND Covered
Page 347 and 348:
PROZAC CAP 40MG SELECTIVE‐SEROTON
Page 349 and 350:
PYRIDOSTIGM TAB 60MG PARASYMPATHOMI
Page 351 and 352:
QUINIDINE SU TAB 300MG ER CLASS IA
Page 353 and 354:
RAPID‐D INF MIS 43"/8MM DEVICES B
Page 355 and 356:
REGENECARE GEL ANTIPRURITICS AND LO
Page 357 and 358:
RENACIDIN SOL IRR IRRIGATING SOLUTI
Page 359 and 360:
RESCRIPTOR TAB 100 MG NONNUCLEOSIDE
Page 361 and 362:
RETISERT IMP 0.59MG CORTICOSTEROIDS
Page 363 and 364:
RIFAMPIN INJ 600 MG ANTITUBERCULOSI
Page 365 and 366:
RITUXAN INJ 500MG ANTINEOPLASTIC AG
Page 367 and 368:
ROPINIROLE TAB 6MG ER NONERGOT‐DE
Page 369 and 370:
SAFETY PEG MIS KIT 20FR DEVICES BRA
Page 371 and 372:
SALVAX DUO KIT PLUS KERATOLYTIC AGE
Page 373 and 374:
SCOPOLAMINE INJ 0.4MG/ML ANTIMUSCAR
Page 375 and 376:
SENILEZOL ELX IRON PREPARATIONS GEN
Page 377 and 378:
SEROQUEL TAB 50MG ATYPICAL ANTIPSYC
Page 379 and 380:
SILICONE MSK MIS PED DEVICES GENERI
Page 381 and 382:
SINGULAIR TAB 10MG LEUKOTRIENE MODI
Page 383 and 384:
SOD POLY SUL SUS 15GM/60 POTASSIUM
Page 385 and 386:
SOLODYN TAB 90MG SKIN AND MUCOUS ME
Page 387 and 388:
SOTALOL AF TAB 80MG BETA‐ADRENERG
Page 389 and 390:
SPRYCEL TAB 100MG ANTINEOPLASTIC AG
Page 391 and 392:
STOPCOCK MIS 1‐WAY DEVICES BRAND
Page 393 and 394:
SUDATEX‐DM TAB ANTITUSSIVES GENER
Page 395 and 396:
SUPPORT‐500 CAP MULTIVITAMIN PREP
Page 397 and 398:
SURGIFOAM MIS 12‐7MM HEMOSTATICS
Page 399 and 400:
SYMBYAX CAP 6‐25MG SELECTIVE‐SE
Page 401 and 402:
T.E.D. MIS XSM/LONG DEVICES BRAND E
Page 403 and 404:
TASMAR TAB 100MG CATECHOL‐O‐ ME
Page 405 and 406:
TEGRETOL XR TAB 200MG ANTICONVULSAN
Page 407 and 408:
TEQUILA SUNR LIQ FLAVOR PHARMACEUTI
Page 409 and 410:
TEV‐TROPIN INJ 5MG SOMATOTROPIN A
Page 411 and 412:
THERABENZAPR PAK ‐90‐5 CENTRALL
Page 413 and 414:
THORA‐SEAL MIS III UNIT DEVICES B
Page 415 and 416:
TIMOLOL GEL SOL 0.25% OP TIMOLOL GE
Page 417 and 418:
TIZANIDINE TAB 2MG CENTRALLY ACTING
Page 419 and 420:
TOLMETIN SOD TAB 200MG OTHER NONSTE
Page 421 and 422:
TOPIRAMATE TAB 25MG ANTICONVULSANTS
Page 423 and 424:
TRANDO/VERAP TAB 4‐240 CR CALCIUM
Page 425 and 426:
TRETINOIN GEL 0.01% CELL STIMULANTS
Page 427 and 428:
TRIAZ PAD 9% LOCAL ANTI‐INFECTIVE
Page 429 and 430:
TRILIPIX CAP 135MG FIBRIC ACID DERI
Page 431 and 432:
TROCHE MOLD MIS 30 CAVIT DEVICES BR
Page 433 and 434:
TYLOX CAP 5‐500MG OPIATE AGONISTS
Page 435 and 436:
ULTRAVATE KIT PAC ANTI‐INFLAMMATO
Page 437 and 438:
UNITHROID TAB 50MCG THYROID AGENTS
Page 439 and 440:
UROGESIC‐ TAB BLUE URINARY ANTI
Page 441 and 442:
VALTURNA TAB 300‐320 RENIN INHIBI
Page 443 and 444:
VAYACOG CAP OTHER MISCELLANEOUS THE
Page 445 and 446:
VENOMIL KIT HONEYBEE OTHER MISCELLA
Page 447 and 448:
VERDESO AER 0.05% ANTI‐INFLAMMATO
Page 449 and 450:
VIBATIV INJ 250MG GLYCOPEPTIDES BRA
Page 451 and 452:
VINATE ONE TAB MULTIVITAMIN PREPARA
Page 453 and 454:
VITACIRC‐B TAB VITAMIN B COMPLEX
Page 455 and 456:
VORTEX/MASK MIS TODDLER DEVICES BRA
Page 457 and 458:
WELLBUTRIN TAB 100MG SR ANTIDEPRESS
Page 459 and 460:
WINRHO SDF INJ 5000UNIT SERUMS BRAN
Page 461 and 462:
XIGRIS INJ 5MG OTHER MISCELLANEOUS
Page 463 and 464:
XYLO‐MPF/EPI INJ 1.5% LOCAL ANEST
Page 465 and 466:
ZANAFLEX CAP 4MG CENTRALLY ACTING S
Page 467 and 468:
ZENCHENT TAB CONTRACEPTIVES GENERIC
Page 469 and 470:
ZIANA GEL SKIN AND MUCOUS MEMBRANE
Page 471 and 472:
ZOCOR TAB 5MG HMG‐COA REDUCTASE I
Page 473 and 474:
ZOSYN INJ 3‐0.375G EXTENDED‐SPE
Page 475 and 476:
ZYPREXA TAB 15MG ATYPICAL ANTIPSYCH
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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