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

BACTOCILL INJ DEX 2GM
PENICILLINASE‐RESISTANT
PENICILLINS BRAND Covered TIER 3
BACTRIM TAB 400‐80MG SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3
BACTRIM DS TAB 800‐160 SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3
BACTROBAN CRE 2%
ANTIBACTERIALS (SKIN & MUCOUS
MEMBRANE) BRAND Covered TIER 3
BACTROBAN OIN 2%
ANTIBACTERIALS (SKIN & MUCOUS
MEMBRANE) Brand‐O PA TIER 3
BACTROBAN OIN NASAL 2%
ANTIBACTERIALS (SKIN & MUCOUS
MEMBRANE) BRAND Covered TIER 3
BAL IN OIL INJ 100MG/ML HEAVY METAL ANTAGONISTS BRAND Covered TIER 3
BAL SALT SOL OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1
BALACALL DM SYP 5‐2‐10MG ANTITUSSIVES GENERIC Covered TIER 1
BALANCED SAL SOL OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1
BAL‐CARE MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3
BAL‐CARE DHA MIS ESSNTIAL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3
BALSALAZIDE CAP 750MG
ANTI‐INFLAMMATORY AGENTS (GI
DRUGS) GENERIC Covered TIER 1
BALZIVA TAB CONTRACEPTIVES GENERIC Covered TIER 1
BANANA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99
BANANA CREME LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99
BANZEL SUS 40MG/ML
ANTICONVULSANTS,
MISCELLANEOUS BRAND Covered TIER 3 QL
BANZEL TAB 200MG
ANTICONVULSANTS,
MISCELLANEOUS BRAND Covered TIER 2 QL
BANZEL TAB 400MG
ANTICONVULSANTS,
MISCELLANEOUS BRAND Covered TIER 2 QL
BARACLUDE SOL .05MG/ML NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2
BARACLUDE TAB 0.5MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2
BARACLUDE TAB 1MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2
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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