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 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