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 StatusCONTRACEPTIVES EMOQUETTE TAB GENERIC TIER 01ENPRESSE‐28 TAB GENERIC TIER 01ERRIN TAB 0.35MG GENERIC TIER 01ESTROSTEP FE TAB Brand‐O TIER 03 PAFALMINA TAB GENERIC TIER 01FEMCON FE CHW Brand‐O TIER 03 PAGENERESS FE CHW BRAND TIER 03GIANVI TAB 3‐0.02MG GENERIC TIER 01GILDESS FE TAB 1.5/30 GENERIC TIER 01GILDESS FE TAB 1/20 GENERIC TIER 01HEATHER TAB 0.35MG GENERIC TIER 01IMPLANON IMP 68MG BRAND TIER 99 DEINTROVALE TAB GENERIC TIER 01JOLESSA TAB GENERIC TIER 01JOLIVETTE TAB 0.35MG GENERIC TIER 01JUNEL 1.5/30 TAB GENERIC TIER 01JUNEL 1/20 TAB GENERIC TIER 01JUNEL FE TAB 1.5/30 GENERIC TIER 01JUNEL FE TAB 1/20 GENERIC TIER 01KARIVA TAB 28 DAY GENERIC TIER 01KELNOR TAB 1/35 GENERIC TIER 01LEENA TAB GENERIC TIER 01LESSINA‐28 TAB GENERIC TIER 01LEVONEST TAB GENERIC TIER 01LEVONOR/ETHI TAB ESTRADIO GENERIC TIER 01LEVONORGESTR TAB 0.75MG GENERIC TIER 01LEVORA‐28 TAB 0.15/30 GENERIC TIER 01LO LOESTRIN TAB BRAND TIER 02LO/OVRAL‐28 TAB Brand‐O TIER 03 PALOESTRIN TAB 1/20‐21 Brand‐O TIER 03 PALOESTRIN 21 TAB 1.5/30 Brand‐O TIER 03 PALOESTRIN 24 TAB FE BRAND TIER 02LOESTRIN FE TAB 1.5/30 Brand‐O TIER 03 PALOESTRIN FE TAB 1/20 Brand‐O TIER 03 PALORYNA TAB 3‐0.02MG GENERIC TIER 01LOSEASONIQUE TAB Brand‐O TIER 03 PALOW‐OGESTREL TAB GENERIC TIER 01LUTERA TAB GENERIC TIER 01LYBREL TAB 90‐20MCG Brand‐O TIER 03 PAKey: 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= DrugExclusion94