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

ATROPEN INJ 2MG
ANTIMUSCARINICS/ANTISPASMODIC
S BRAND Covered TIER 3
ATROPIN‐CARE SOL 1% OP MYDRIATICS GENERIC Covered TIER 1
ATROPINE SUL INJ 0.05MG/1
ANTIMUSCARINICS/ANTISPASMODIC
S GENERIC Covered TIER 1
ATROPINE SUL INJ 0.1MG/ML
ANTIMUSCARINICS/ANTISPASMODIC
S GENERIC Covered TIER 1
ATROPINE SUL INJ 0.4/0.5
ANTIMUSCARINICS/ANTISPASMODIC
S GENERIC Covered TIER 1
ATROPINE SUL INJ 0.4MG/ML
ANTIMUSCARINICS/ANTISPASMODIC
S GENERIC Covered TIER 1
ATROPINE SUL INJ 1MG/ML
ANTIMUSCARINICS/ANTISPASMODIC
S GENERIC Covered TIER 1
ATROPINE SUL OIN 1% OP MYDRIATICS GENERIC Covered TIER 1
ATROPINE SUL SOL 1% OP MYDRIATICS GENERIC Covered TIER 1
ATROPINUM SUB COMPOSIT
OTHER MISCELLANEOUS
THERAPEUTIC AGENTS BRAND Excluded TIER 99
ATROVENT HFA AER 17MCG
ANTIMUSCARINICS/ANTISPASMODIC
S BRAND Covered TIER 2 QL
ATROVENT NAS SOL 0.03%
ANTIMUSCARINICS/ANTISPASMODIC
S Brand‐O PA TIER 3
ATROVENT NAS SOL 0.06%
ANTIMUSCARINICS/ANTISPASMODIC
S Brand‐O PA TIER 3
ATRYN INJ 1750 ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3
ATUSS DS SUS ANTITUSSIVES Brand‐O PA TIER 99
AUBAGIO TAB 14MG
OTHER MISCELLANEOUS
THERAPEUTIC AGENTS BRAND Covered TIER 3
AUBAGIO TAB 7MG
OTHER MISCELLANEOUS
THERAPEUTIC 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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