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

BETOPTIC‐S SUS 0.25% OP
BETA‐ADRENERGIC BLOCKING
AGENTS (EENT) BRAND Covered TIER 2
BEXXAR CON 14MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP
BEXXAR 131 I INJ 0.61/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3
BEXXAR 131 I INJ 5.6MCI/M ANTINEOPLASTIC AGENTS BRAND Covered TIER 3
BEYAZ TAB CONTRACEPTIVES BRAND Covered TIER 2
BIAFINE EMU
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. BRAND Excluded TIER 99
BIAXIN SUS 250/5ML OTHER MACROLIDES Brand‐O PA TIER 3
BIAXIN TAB 250MG OTHER MACROLIDES Brand‐O PA TIER 3
BIAXIN TAB 500MG OTHER MACROLIDES Brand‐O PA TIER 3
BIAXIN XL TAB 500MG OTHER MACROLIDES Brand‐O PA TIER 3
BIAXIN XL TAB PAC 500 OTHER MACROLIDES Brand‐O PA TIER 3
BICALUTAMIDE TAB 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1
BICILLIN C‐R INJ 1200000 NATURAL PENICILLINS BRAND Covered TIER 3
BICILLIN C‐R INJ 900/300 NATURAL PENICILLINS BRAND Covered TIER 3
BICILLIN L‐A INJ 1200000 NATURAL PENICILLINS BRAND Covered TIER 3
BICILLIN L‐A INJ 2400000 NATURAL PENICILLINS BRAND Covered TIER 3
BICILLIN L‐A INJ 600000 NATURAL PENICILLINS BRAND Covered TIER 3
BICNU INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP
BIDHIST‐D TAB 6‐45MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1
BIDIL TAB NITRATES AND NITRITES BRAND Covered TIER 2
BIFERARX TAB IRON PREPARATIONS BRAND Covered TIER 3
BILTRICIDE TAB 600MG ANTHELMINTICS BRAND Covered TIER 2
BINOSTO TAB 70MG BONE RESORPTION INHIBITORS BRAND Covered TIER 3
BIO GLO TES 1MG OP OCULAR DISORDERS GENERIC Covered TIER 1
BIOCEL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1
BIOGESIC TAB 30‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1
BIONECT CRE 0.2%
SKIN AND MUCOUS MEMBRANE
AGENTS, MISC. BRAND Excluded TIER 99
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
50