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

ACETAZOLAMID TAB 250MG
CARBONIC ANHYDRASE INHIBITORS
(EENT) GENERIC Covered TIER 1
ACETIC ACID SOL 0.25%IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1
ACETIC ACID SOL 2% OTIC EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1
ACETYLCYST SOL 10% ANTIDOTES GENERIC Covered TIER 1
ACETYLCYST SOL 20% ANTIDOTES GENERIC Covered TIER 1
ACID JELLY GEL VAG/APPL
LOCAL ANTI‐INFECTIVES,
MISCELLANEOUS GENERIC Covered TIER 1
ACIPHEX TAB 20MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL
ACLARO EMU DEPIGMENTING AGENTS BRAND Excluded TIER 99
ACLARO PD EMU 4% DEPIGMENTING AGENTS BRAND Excluded TIER 99
ACLOVATE CRE 0.05%
ANTI‐INFLAMMATORY AGENTS (SKIN
& MUCOUS) Brand‐O PA TIER 3
DISEASE‐MODIFYING
ACTEMRA INJ 200/10ML
ANTIRHEUMATIC AGENTS BRAND PA TIER 3 SP
ACTEMRA INJ 400/20ML
DISEASE‐MODIFYING
ANTIRHEUMATIC AGENTS BRAND PA TIER 3 SP
ACTEMRA INJ 80MG/4ML
DISEASE‐MODIFYING
ANTIRHEUMATIC AGENTS BRAND PA TIER 3 SP
ACTHAR HP INJ 80UNIT PITUITARY BRAND Covered TIER 2 SP
ACTHIB INJ VACCINES BRAND Covered TIER 3
ACTHREL INJ 100MCG PITUITARY FUNCTION BRAND Covered TIER 3
ACTICIN CRE 5% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1
ACTIFOAM MIS 12.7X8.9 HEMOSTATICS BRAND Excluded TIER 99
ACTIFOAM MIS 7X5X0.6 HEMOSTATICS BRAND Excluded TIER 99
ACTIGALL CAP 300MG CHOLELITHOLYTIC AGENTS Brand‐O PA TIER 3
ACTIMMUNE INJ 2MU/0.5 BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP
ACTIQ LOZ 1200MCG OPIATE AGONISTS Brand‐O PA TIER 3 QL
ACTIQ LOZ 1600MCG OPIATE AGONISTS Brand‐O PA TIER 3 QL
ACTIQ LOZ 200MCG OPIATE AGONISTS Brand‐O PA TIER 3 QL
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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