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

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AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCONTRACEPTIVES ORTHO TRI‐ TAB CYCLN LO BRAND TIER 03ORTHO‐CEPT TAB 28 Brand‐O TIER 03 PAORTHO‐CYCLEN TAB 0.25/35 Brand‐O TIER 03 PAORTHO‐NOVUM TAB 1/35‐28 Brand‐O TIER 03 PAORTHO‐NOVUM TAB 7/7/7‐28 Brand‐O TIER 03 PAOVCON 50 TAB 28 BRAND TIER 03OVCON‐35 TAB Brand‐O TIER 03 PAPHILITH TAB 0.4‐35 GENERIC TIER 01PLAN B TAB 0.75MG Brand‐O TIER 03 PAPLAN B TAB 1.5MG Brand‐O TIER 03 PAPORTIA‐28 TAB GENERIC TIER 01PREVIFEM TAB GENERIC TIER 01QUASENSE TAB GENERIC TIER 01RECLIPSEN TAB GENERIC TIER 01SAFYRAL TAB BRAND TIER 02SEASONALE TAB Brand‐O TIER 03 PASEASONIQUE TAB Brand‐O TIER 03 PASOLIA TAB GENERIC TIER 01SPRINTEC 28 TAB 28 DAY GENERIC TIER 01SRONYX TAB GENERIC TIER 01SYEDA TAB 3‐0.03MG GENERIC TIER 01TILIA FE TAB GENERIC TIER 01TRI‐LEGEST TAB FE GENERIC TIER 01TRINESSA TAB GENERIC TIER 01TRI‐NORINYL TAB 28 Brand‐O TIER 03 PATRI‐PREVIFEM TAB GENERIC TIER 01TRI‐SPRINTEC TAB GENERIC TIER 01TRIVORA‐28 TAB GENERIC TIER 01VELIVET PAK GENERIC TIER 01VESTURA TAB 3‐0.02MG GENERIC TIER 01VIORELE TAB GENERIC TIER 01WERA TAB 0.5/35 GENERIC TIER 01WYMZYA FE CHW 0.4MG‐35 GENERIC TIER 01YASMIN 28 TAB 3‐0.03MG Brand‐O TIER 03 PAYAZ TAB 3‐0.02MG Brand‐O TIER 02 PAZARAH TAB GENERIC TIER 01ZENCHENT TAB GENERIC TIER 01ZENCHENT FE CHW 0.4MG‐35 GENERIC TIER 01ZEOSA CHW GENERIC TIER 01Key: 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= DrugExclusion96
AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusCONTRACEPTIVES ZOVIA 1/35E TAB GENERIC TIER 01ZOVIA 1/50E TAB GENERIC TIER 01CONTRACEPTIVES (E.G. FOAMS, DEVICES) FEMCAP MIS 22MM BRAND TIER 99 DEFEMCAP MIS 26MM BRAND TIER 99 DEFEMCAP MIS 30MM BRAND TIER 99 DEOMNIFLEX DPR BRAND TIER 03ORTHO COIL DPR KIT 100 BRAND TIER 03ORTHO COIL DPR KIT 105 BRAND TIER 03ORTHO COIL DPR KIT 50 BRAND TIER 03ORTHO FLAT DPR KIT 55 BRAND TIER 03ORTHO FLAT DPR KIT 60 BRAND TIER 03ORTHO FLAT DPR KIT 65 BRAND TIER 03ORTHO FLAT DPR KIT 70 BRAND TIER 03ORTHO FLAT DPR KIT 75 BRAND TIER 03ORTHO FLAT DPR KIT 80 BRAND TIER 03ORTHO FLAT DPR KIT 85 BRAND TIER 03ORTHO FLAT DPR KIT 90 BRAND TIER 03ORTHO FLAT DPR KIT 95 BRAND TIER 03ORTHO FLEX DPR 65MM BRAND TIER 03ORTHO FLEX DPR 70MM BRAND TIER 03ORTHO FLEX DPR 75MM BRAND TIER 03ORTHO FLEX DPR 80MM BRAND TIER 03PARAGARD IUD T380A BRAND TIER 03PRENTIF MIS 22MM BRAND TIER 99 DEPRENTIF MIS 25MM BRAND TIER 99 DEPRENTIF MIS 28MM BRAND TIER 99 DEPRENTIF MIS 31MM BRAND TIER 99 DEPRENTIF MIS FITTING BRAND TIER 03WIDE‐SEAL DPR KIT 60 BRAND TIER 03WIDE‐SEAL DPR KIT 65 BRAND TIER 03WIDE‐SEAL DPR KIT 70 BRAND TIER 03WIDE‐SEAL DPR KIT 75 BRAND TIER 03WIDE‐SEAL DPR KIT 80 BRAND TIER 03WIDE‐SEAL DPR KIT 85 BRAND TIER 03WIDE‐SEAL DPR KIT 90 BRAND TIER 03WIDE‐SEAL DPR KIT 95 BRAND TIER 03CORTICOSTEROIDS (EENT) ACETASOL HC SOL OTIC GENERIC TIER 01AERO OTIC HC SOL GENERIC TIER 99 DEALREX SUS 0.2% BRAND TIER 02 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= DrugExclusion97
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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