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 MARLISSA TAB 0.15/30 GENERIC TIER 01MICROGESTIN TAB 1.5/30 GENERIC TIER 01MICROGESTIN TAB 1/20 GENERIC TIER 01MICROGESTIN TAB FE 1/20 GENERIC TIER 01MICROGESTIN TAB FE1.5/30 GENERIC TIER 01MIRCETTE TAB 28 DAY Brand‐O TIER 03 PAMIRENA IUD SYSTEM BRAND TIER 03MODICON TAB 0.5/35 Brand‐O TIER 03 PAMONONESSA TAB GENERIC TIER 01MYZILRA TAB GENERIC TIER 01NATAZIA TAB BRAND TIER 02NECON TAB 0.5/35 GENERIC TIER 01NECON TAB 1/35‐28 GENERIC TIER 01NECON TAB 1/50‐28 GENERIC TIER 01NECON TAB 10/11‐28 GENERIC TIER 01NECON 7/7/7 TAB 28 DAY GENERIC TIER 01NEXPLANON IMP 68MG BRAND TIER 99 DENEXT CHOICE TAB 0.75MG GENERIC TIER 01NEXT CHOICE TAB 1.5MG GENERIC TIER 01NORA‐BE TAB 0.35MG GENERIC TIER 01NORDETTE‐28 TAB Brand‐O TIER 03 PANORETHINDRON TAB 0.35MG GENERIC TIER 01NORGEST/ETH TAB ESTRAD GENERIC TIER 01NORGEST/ETHI TAB 0.25/35 GENERIC TIER 01NORGEST/ETHI TAB ESTRADIO GENERIC TIER 01NORINYL TAB 1+35‐28 Brand‐O TIER 03 PANORINYL TAB 1+50‐28 BRAND TIER 03NOR‐QD TAB 0.35MG Brand‐O TIER 03 PANORTREL (21) TAB 1/35 GENERIC TIER 01NORTREL (28) TAB 1/35 GENERIC TIER 01NORTREL 28 TAB 0.5/35 GENERIC TIER 01NORTREL7/7/7 TAB 28 DAYS GENERIC TIER 01NUVARING MIS BRAND TIER 02OCELLA TAB 3‐0.03MG GENERIC TIER 01OGESTREL TAB GENERIC TIER 01ORSYTHIA TAB GENERIC TIER 01ORTHO EVRA DIS WEEK BRAND TIER 03ORTHO MICRON TAB 0.35MG Brand‐O TIER 03 PAORTHO TRI‐ TAB CYCLEN 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= DrugExclusion95