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

AXERT TAB 6.25MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL
AXID CAP 150MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3
AXID CAP 300MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3
AXID SOL 15MG/ML HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 2
AXIRON SOL 30MG/ACT ANDROGENS BRAND Covered TIER 2
AXONA POW CALORIC AGENTS BRAND Excluded TIER 99
AYGESTIN TAB 5MG PROGESTINS Brand‐O PA TIER 3
AZ CREAM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99
AZACTAM INJ 1GM MONOBACTAMS Brand‐O PA TIER 3
AZACTAM INJ 2GM MONOBACTAMS Brand‐O PA TIER 3
AZACTAM/DEX INJ 1GM MONOBACTAMS BRAND Covered TIER 3
AZACTAM/DEX INJ 2GM MONOBACTAMS BRAND Covered TIER 3
AZASAN TAB 100MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2
AZASAN TAB 75 MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2
AZASITE SOL 1% ANTIBACTERIALS (EENT) BRAND Covered TIER 3
AZATHIOPRINE INJ 100MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1
AZATHIOPRINE TAB 50MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1
AZELASTINE DRO 0.05% ANTIALLERGIC AGENTS GENERIC Covered TIER 1
AZELASTINE SPR 0.1% ANTIALLERGIC AGENTS GENERIC Covered TIER 1
AZELEX CRE 20%
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. BRAND Covered TIER 2
AZILECT TAB 0.5MG MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 2
AZILECT TAB 1MG MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 2
AZITHROMYCIN INJ 2.5GM OTHER MACROLIDES GENERIC Covered TIER 1
AZITHROMYCIN INJ 500MG OTHER MACROLIDES GENERIC Covered TIER 1
AZITHROMYCIN POW 1GM PAK OTHER MACROLIDES GENERIC Covered TIER 1
AZITHROMYCIN SUS 100/5ML OTHER MACROLIDES GENERIC Covered TIER 1
AZITHROMYCIN SUS 200/5ML OTHER MACROLIDES 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
40