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

AMPICILLIN INJ 125MG AMINOPENICILLINS GENERIC Covered TIER 1
AMPICILLIN INJ 1GM AMINOPENICILLINS GENERIC Covered TIER 1
AMPICILLIN INJ 250MG AMINOPENICILLINS GENERIC Covered TIER 1
AMPICILLIN INJ 2GM AMINOPENICILLINS GENERIC Covered TIER 1
AMPICILLIN INJ 500MG AMINOPENICILLINS GENERIC Covered TIER 1
AMPICILLIN SUS 125/5ML AMINOPENICILLINS GENERIC Covered TIER 1
AMPICILLIN SUS 250/5ML AMINOPENICILLINS GENERIC Covered TIER 1
AMP‐SULBACTA INJ 1.5GM AMINOPENICILLINS GENERIC Covered TIER 1
AMP‐SULBACTA INJ 1‐0.5GM AMINOPENICILLINS GENERIC Covered TIER 1
AMP‐SULBACTA INJ 10‐5GM AMINOPENICILLINS GENERIC Covered TIER 1
AMP‐SULBACTA INJ 15GM AMINOPENICILLINS GENERIC Covered TIER 1
AMP‐SULBACTA INJ 2‐1GM AMINOPENICILLINS GENERIC Covered TIER 1
AMP‐SULBACTA INJ 3GM AMINOPENICILLINS GENERIC Covered TIER 1
AMPYRA TAB 10MG
OTHER MISCELLANEOUS
THERAPEUTIC AGENTS BRAND PA TIER 3 QL SP
AMRIX CAP 15MG
CENTRALLY ACTING SKELETAL
MUSCLE RELAXNT BRAND Covered TIER 3
AMRIX CAP 30MG
CENTRALLY ACTING SKELETAL
MUSCLE RELAXNT BRAND Covered TIER 3
AMTURNIDE150 TAB ‐5‐12.5 RENIN INHIBITORS BRAND Covered TIER 2
AMTURNIDE300 TAB ‐10‐12.5 RENIN INHIBITORS BRAND Covered TIER 2
AMTURNIDE300 TAB ‐10‐25MG RENIN INHIBITORS BRAND Covered TIER 2
AMTURNIDE300 TAB ‐5‐12.5 RENIN INHIBITORS BRAND Covered TIER 2
AMTURNIDE300 TAB ‐5‐25MG RENIN INHIBITORS BRAND Covered TIER 2
AMVISC INJ 12MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3
AMVISC PLUS INJ 16MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3
AMYL NITRITE INH 0.3ML NITRATES AND NITRITES GENERIC Covered TIER 1
AMYTAL SOD INJ 500MG
BARBITURATES (ANXIOLYTIC,
SEDATIVE/HYP) BRAND Covered TIER 3
AMYVID INJ RADIOACTIVE AGENTS 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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