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

ANAPROX TAB 275MG
OTHER NONSTEROIDAL ANTI‐
INFLAM. AGENTS Brand‐O PA TIER 3
ANAPROX DS TAB 550MG
OTHER NONSTEROIDAL ANTI‐
INFLAM. AGENTS Brand‐O PA TIER 3
ANASCORP INJ SERUMS BRAND Covered TIER 3
ANASPAZ TAB 0.125MG
ANTIMUSCARINICS/ANTISPASMODIC
S Brand‐O PA TIER 3
ANASTROZOLE TAB 1MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1
ANCOBON CAP 250MG PYRIMIDINES Brand‐O PA TIER 3
ANCOBON CAP 500MG PYRIMIDINES Brand‐O PA TIER 3
ANDRODERM DIS 2.5MG/24 ANDROGENS BRAND Covered TIER 2
ANDRODERM DIS 2MG/24HR ANDROGENS BRAND Covered TIER 2
ANDRODERM DIS 4MG/24HR ANDROGENS BRAND Covered TIER 2
ANDRODERM DIS 5MG/24HR ANDROGENS BRAND Covered TIER 2
ANDROGEL GEL 1%(25MG) ANDROGENS BRAND Covered TIER 2
ANDROGEL GEL 1%(50MG) ANDROGENS BRAND Covered TIER 2
ANDROGEL GEL 1.62% ANDROGENS BRAND Covered TIER 2
ANDROGEL GEL PUMP 1% ANDROGENS BRAND Covered TIER 2
ANDROID CAP 10MG ANDROGENS BRAND Covered TIER 3
ANDROXY TAB 10MG ANDROGENS BRAND Covered TIER 2
ANECTINE INJ 20MG/ML
NEUROMUSCULAR BLOCKING
AGENTS Brand‐O PA TIER 3
ANESTH NEEDL MIS 23X1‐3/8 DEVICES GENERIC Excluded TIER 99
ANGEL WING MIS 19GX3/4" DEVICES BRAND Excluded TIER 99
ANGEL WING MIS 21GX3/4" DEVICES BRAND Excluded TIER 99
ANGEL WING MIS 23GX3/4" DEVICES BRAND Excluded TIER 99
ANGEL WING MIS 25GX3/4" DEVICES BRAND Excluded TIER 99
ANGEL WING MIS TRANSFER DEVICES BRAND Excluded TIER 99
ANGEL WING MIS TUBE HLD DEVICES BRAND Excluded TIER 99
ANGELIQ TAB 0.25‐0.5 ESTROGENS 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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