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

ADULT MASK MIS DEVICES GENERIC Excluded TIER 99
ADULT MASK MIS LARGE DEVICES GENERIC Excluded TIER 99
ADVAIR DISKU AER 100/50
SELECTIVE BETA‐2‐ADRENERGIC
AGONISTS BRAND Covered TIER 3 QL
ADVAIR DISKU AER 250/50
SELECTIVE BETA‐2‐ADRENERGIC
AGONISTS BRAND Covered TIER 3 QL
ADVAIR DISKU AER 500/50
SELECTIVE BETA‐2‐ADRENERGIC
AGONISTS BRAND Covered TIER 3 QL
ADVAIR HFA AER 115/21
SELECTIVE BETA‐2‐ADRENERGIC
AGONISTS BRAND Covered TIER 3 QL
ADVAIR HFA AER 230/21
SELECTIVE BETA‐2‐ADRENERGIC
AGONISTS BRAND Covered TIER 3 QL
ADVAIR HFA AER 45/21
SELECTIVE BETA‐2‐ADRENERGIC
AGONISTS BRAND Covered TIER 3 QL
ADVANCED MIS AM/PM MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3
ADVATE INJ 1000UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVATE INJ 1500UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVATE INJ 2000UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVATE INJ 250UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVATE INJ 3000UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVATE INJ 4000UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVATE INJ 500UNIT HEMOSTATICS BRAND Covered TIER 2 SP
ADVICOR TAB 1000‐20 HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3
ADVICOR TAB 1000‐40 HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3
ADVICOR TAB 500‐20MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3
ADVICOR TAB 750‐20MG HMG‐COA REDUCTASE INHIBITORS 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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