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

ARMOUR THYRO TAB 60MG THYROID AGENTS Brand‐O PA TIER 3
ARMOUR THYRO TAB 90MG THYROID AGENTS Brand‐O PA TIER 3
ARNICA TIN FLOWER
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. GENERIC Covered TIER 1
AROMASIN TAB 25MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3
ARRANON INJ 5MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP
ARTHROTEC 50 TAB
OTHER NONSTEROIDAL ANTI‐
INFLAM. AGENTS BRAND Covered TIER 3
ARTHROTEC 75 TAB
OTHER NONSTEROIDAL ANTI‐
INFLAM. AGENTS BRAND Covered TIER 3
ARTISS SOL 10ML
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. BRAND Covered TIER 3
ARTISS SOL 2ML
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. BRAND Covered TIER 3
ARTISS SOL 4ML
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. BRAND Covered TIER 3
ARZERRA CON 100/50ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP
ARZERRA CON 100/5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP
ARZOL SILVER MIS NITR APP
EENT ANTI‐INFECTIVES,
MISCELLANEOUS GENERIC Covered TIER 1
ASACOL TAB 400MG DR
ANTI‐INFLAMMATORY AGENTS (GI
DRUGS) BRAND Covered TIER 2
ASACOL HD TAB 800MG
ANTI‐INFLAMMATORY AGENTS (GI
DRUGS) BRAND Covered TIER 2
ASCLERA INJ 0.5% SCLEROSING AGENTS BRAND Covered TIER 3
ASCLERA INJ 1% SCLEROSING AGENTS BRAND Covered TIER 3
ASCOMP/COD CAP 30MG OPIATE AGONISTS GENERIC Covered TIER 1
ASCOR L 500 INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1
ASCOR L NC INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1
ASCORBIC ACD INJ 500MG/ML VITAMIN C 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
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