Depo-Subq Provera 104 Susy
104MG/0.65ML
PROGESTIN CONTRACEPTIVES - INJECTABLE
Also known as:
DEPO-SUBQ PROVERA 104 SUSY 104MG/0.65ML
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Standard Option 2026 | Tier 2 - Preferred Brand | — | — | — NCTM | None |
| BCBS Federal Basic Option 2026 | Tier 2 - Preferred Brand | — | — | — NCTM | None |
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | — | — | — NCTM | None |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 0 - $0 Copay (ACA Preventive) | — | — | ✓ | QL |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 0 - $0 Copay (ACA Preventive) | — | — | ✓ | QL |
| NC State Health Plan - HDHP 2026 | Tier 0 - $0 Copay (ACA Preventive) | — | — | ✓ | QL |