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

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusESTROGENS DEPO‐ESTRADI INJ 5MG/ML BRAND TIER 03DIVIGEL GEL 0.25MG BRAND TIER 02DIVIGEL GEL 0.5MG BRAND TIER 02DIVIGEL GEL 1MG/GM BRAND TIER 02EEMT TAB GENERIC TIER 99 DEEEMT HS TAB GENERIC TIER 99 DEELESTRIN GEL 0.06% BRAND TIER 03ENJUVIA TAB 0.3MG BRAND TIER 02ENJUVIA TAB 0.45MG BRAND TIER 02ENJUVIA TAB 0.625MG BRAND TIER 02ENJUVIA TAB 0.9MG BRAND TIER 02ENJUVIA TAB 1.25MG BRAND TIER 02ESSIAN TAB GENERIC TIER 99 DEESSIAN H.S. TAB GENERIC TIER 99 DEEST ESTROGEN TAB MTEST GENERIC TIER 99 DEEST ESTROGEN TAB MTEST DS GENERIC TIER 99 DEEST ESTROGEN TAB MTEST HS GENERIC TIER 99 DEESTRA/NORETH TAB 0.5‐0.1 GENERIC TIER 01ESTRA/NORETH TAB 1‐0.5MG GENERIC TIER 01ESTRACE TAB 0.5MG Brand‐O TIER 03 PAESTRACE TAB 1MG Brand‐O TIER 03 PAESTRACE TAB 2MG Brand‐O TIER 03 PAESTRACE VAG CRE 0.1MG/GM BRAND TIER 02ESTRAD VAL INJ 10MG/ML GENERIC TIER 01ESTRAD VAL INJ 200MG/5 GENERIC TIER 01ESTRAD VAL INJ 20MG/ML GENERIC TIER 01ESTRAD VAL INJ 40MG/ML GENERIC TIER 01ESTRADERM DIS 0.05MG BRAND TIER 03ESTRADERM DIS 0.1MG BRAND TIER 03ESTRADIOL DIS 0.025MG GENERIC TIER 01ESTRADIOL DIS 0.0375MG GENERIC TIER 01ESTRADIOL DIS 0.05MG GENERIC TIER 01ESTRADIOL DIS 0.06MG GENERIC TIER 01ESTRADIOL DIS 0.075MG GENERIC TIER 01ESTRADIOL DIS 0.1MG GENERIC TIER 01ESTRADIOL TAB 0.5MG GENERIC TIER 01ESTRADIOL TAB 1MG GENERIC TIER 01ESTRADIOL TAB 2MG GENERIC TIER 01ESTRASORB EMU BRAND TIER 03Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion141