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Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs abacavir abacavir/dolutegravir/lamivudine abacavir/lamivudine abacavir/lamivudine/zidovudine abemaciclib PA abiraterone PA abiraterone PA acalabrutinib PA acarbose acetaminophen acetazolamide acetazolamide ext-rel acetic acid acyclovir caps, susp, tabs acyclovir oint adalimumab PA adapalene crm, gel, pad PA adefovir dipivoxil afatinib PA albendazole albuterol albuterol ext-rel albuterol nebulization solution albuterol sulfate, CFC-free aerosol albuterol sulfate, CFC-free aerosol crm, oint 0.05% alcohol swabs alectinib PA alendronate tabs alendronate/vitamin D3 alfuzosin ext-rel aliskiren ST allopurinol alogliptin alogliptin/metformin alpelisib PA alumina/magnesia

Appendix F7 1 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs alumina/magnesia/simethicone alumina/magnesia/simethicone aluminum chloride solution 20% amantadine caps, syrup amantadine caps, syrup ambrisentan PA amiloride amiloride/hydrochlorothiazide aminocaproic acid amiodarone amlodipine amlodipine/benazepril ammonium lactate 12% amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ext-rel ampicillin anagrelide antipyrine/benzocaine PA aprepitant caps aprepitant susp artificial tears oint, soln aspirin atazanavir atazanavir/cobicistat atenolol atenolol/chlorthalidone atorvastatin atovaquone atovaquone/proguanil atropine solution 1% avapritinib PA axitinib PA azathioprine azathioprine

Appendix F7 2 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs azelastine azelastine spray azithromycin bacitracin bacitracin baclofen balsalazide beclomethasone breath-activated aerosol benazepril benzonatate benzoyl peroxide gel 2.5%, 5%, 10% dipropionate augmented crm 0.05% betamethasone dipropionate augmented gel, oint 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate crm, lotion, oint 0.05% betamethasone valerate crm, lotion, oint 0.1% betamethasone valerate foam 0.12% betaxolol 0.25% bethanechol bexarotene caps PA bictegravir/emtricitabine/tenofovir alafenamide bimatoprost 0.01% bimatoprost 0.03% binimetinib PA bisacodyl delayed-rel tabs bismuth subsalicylate oral bismuth/metronidazole/tetracycline bisoprolol bisoprolol/hydrochlorothiazide blood glucose monitoring kits, test strips blood glucose monitoring kits, test strips blood glucose monitoring kits, test strips blood glucose monitoring kits, test strips blood monitoring test strips bosentan PA bosutinib PA

Appendix F7 3 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs brigatinib PA brimonidine 0.1% brimonidine 0.15% brimonidine 0.2% brimonidine/timolol brinzolamide brodalumab PA bromocriptine brompheniramine/phenylephrine elixir 1 mg/2.5 mg/5 mL budesonide delayed-rel caps budesonide nebulization suspension budesonide/formoterol bumetanide busulfan butalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine/codeine butalbital/aspirin/caffeine butalbital/aspirin/caffeine/codeine butenafine cabergoline cabozantinib PA cabozantinib PA calcipotriene calcipotriene/betamethasone oint calcitonin-salmon spray calcitriol (1,25-D3) calcium acetate/aluminum sulfate powder packet candesartan candesartan/hydrochlorothiazide capecitabine PA captopril captopril/hydrochlorothiazide carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone

Appendix F7 4 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs carisoprodol 350 mg carvedilol cefaclor cefdinir cefixime cefpodoxime cefprozil ceftriaxone cefuroxime axetil celecoxib PA cephalexin ceritinib PA cetirizine soln, tabs cetirizine/pseudoephedrine ext-rel chlorambucil chlordiazepoxide/clidinium chlorhexidine gluconate chloroquine chlorothiazide susp chlorpheniramine chlorthalidone cholecalciferol (D3) drops cholestyramine can ciclopirox crm, gel, shampoo, topical suspension ciclopirox nail lacquer cimetidine cinacalcet PA ciprofloxacin ciprofloxacin otic ciprofloxacin solution ciprofloxacin/ clarithromycin clindamycin clindamycin crm clindamycin foam 1% clindamycin gel, lotion, solution 1%

Appendix F7 5 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs clindamycin/benzoyl peroxide propionate crm, gel, oint, solution 0.05% foam 0.05% clobetasol propionate lotion, shampoo 0.05% clonidine clonidine ext-rel clonidine transdermal clopidogrel clotrimazole clotrimazole clotrimazole clotrimazole crm 1% clotrimazole crm 2% clotrimazole troches clotrimazole/betamethasone cobicistat cobimetinib PA codeine sulfate codeine/acetaminophen codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine colchicine tabs colestipol collagenase PA condoms crizotinib PA cromolyn nebulization solution cromolyn sodium cromolyn sodium cyanocobalamin inj cyclobenzaprine 5 mg, 10 mg cyclophosphamide caps cyclosporine cyclosporine, modified

Appendix F7 6 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs dabigatran dabrafenib PA dacomitinib PA dalfampridine ext-rel PA dantrolene dapsone tabs darbepoetin alfa darifenacin ext-rel PA darunavir darunavir/cobicistat darunavir/cobicistat/emtricitabine/tenofovir alafe dasatinib PA deferasirox PA deferasirox tabs PA desmopressin spray, tabs /EE desogestrel/EE - Velivet desogestrel/EE 0.15/30 - Apri crm, lotion, oint 0.05% crm, oint 0.05% desoximetasone crm, oint 0.25%, gel 0.05% dexamethasone dexamethasone sodium phosphate dextromethorphan/guaifenesin ext-rel dextromethorphan/guaifenesin liquid, solution, syrup dextromethorphan/promethazine dextromethorphan/quinidine diaphragm diclofenac sodium delayed-rel diclofenac sodium gel dicloxacillin dicyclomine didanosine delayed-rel digoxin

Appendix F7 7 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs diltiazem ext-rel 12 hr 60 mg, 90 mg, 120 mg diltiazem ext-rel 24 hr diltiazem ext-rel 24 hr diltiazem ext-rel 24 hr diltiazem ext-rel 24 hr 120 mg, 180 mg, 240 mg dimethyl fumarate delayed-rel PA diphenhydramine diphenoxylate/atropine dipyridamole dipyridamole ext-rel/aspirin disopyramide disopyramide ext-rel 100 mg docusate sodium dofetilide PA dolutegravir dolutegravir/lamivudine dolutegravir/rilpivirine donepezil doravirine doravirine/lamivudine/tenofovir disoproxil fumarat dorzolamide dorzolamide/timolol maleate doxazosin doxercalciferol caps doxorubicin liposomal doxycycline hyclate caps doxycycline hyclate tabs 20 mg, 100 mg doxycycline monohydrate caps 100 mg doxycycline monohydrate susp doxycycline monohydrate tabs doxylamine 25 mg dronedarone /EE 3/20 drospirenone/EE 3/30 dulaglutide ST dutasteride dutasteride/tamsulosin

Appendix F7 8 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs duvelisib PA econazole EE/norethindrone acetate EE/norethindrone acetate - Jinteli efavirenz efavirenz/emtricitabine/tenofovir disoproxil fumar efavirenz/lamivudine/tenofovir disoproxil fumarate efavirenz/lamivudine/tenofovir disoproxil fumarate PA electrolyte rehydrating solution, oral eltrombopag PA elvitegravir/cobicistat/emtricitabine/tenofovir al elvitegravir/cobicistat/emtricitabine/tenofovir di empagliflozin ST empagliflozin/metformin ST empagliflozin/metformin ext-rel ST emtricitabine emtricitabine/rilpivirine/tenofovir alafenamide emtricitabine/rilpivirine/tenofovir disoproxil fum emtricitabine/tenofovir alafenamide emtricitabine/tenofovir disoproxil fumarate enalapril enalapril/hydrochlorothiazide enasidenib PA encorafenib PA enoxaparin PA entacapone entecavir soln entecavir tabs entrectinib PA PA epinephrine auto-injector epinephrine auto-injector epinephrine auto-injector epoetin alfa epoetin alfa epoprostenol sodium PA

Appendix F7 9 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs erdafitinib PA ergocalciferol (D2) caps ergocalciferol (D2) drops ergotamine/caffeine erlotinib PA ertugliflozin ST ertugliflozin/metformin ST ertugliflozin/sitagliptin ST erythromycin erythromycin base erythromycin delayed-rel erythromycin delayed-rel - Ery-tab erythromycin ethylsuccinate erythromycin gel 2% erythromycin solution 2% erythromycin stearate erythromycin/benzoyl peroxide 3%/5% esomeprazole delayed-rel caps, tabs 20 mg estradiol estradiol crm estradiol vaginal tabs estradiol/ , , conjugated crm estrogens, conjugated/medroxyprogesterone estrogens, conjugated/medroxyprogesterone etanercept PA ethambutol ethosuximide ethynodiol diacetate/EE 1/35 - Zovia 1/35 ethynodiol diacetate/EE 1/50 - Kelnor 1/50 etodolac /EE ring etoposide etravirine

Appendix F7 10 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs PA exemestane ezetimibe ST ezetimibe/simvastatin famotidine susp 40 mg/5 mL, tabs 20 mg, 40 mg famotidine tabs 10 mg, 20 mg febuxostat ST fedratinib PA felodipine ext-rel fenofibrate caps 50 mg, 150 mg fenofibrate micronized caps 43 mg, 67 mg, 130 mg, 134 mg, 200 fenofibrate tabs 48 mg, 54 mg, 145 mg, 160 mg fentanyl transdermal PA ferrous gluconate ferrous sulfate fexofenadine susp, tabs fexofenadine/pseudoephedrine ext-rel fidaxomicin PA filgrastim finasteride 5 mg flavoxate flecainide fluconazole fluconazole 150 mg spray acetonide body oil 0.01% crm, oil, solution 0.01% fluocinolone acetonide crm, oint 0.025% fluocinolone acetonide scalp oil 0.01% crm, gel, oint, solution 0.05% 0.1% susp fluorometholone 0.25% fluorometholone oint fluorouracil crm 1% fluorouracil crm 5% fluorouracil solution 2%, 5%

Appendix F7 11 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs fluticasone propionate crm 0.05% fluticasone spray fluticasone spray fluticasone, CFC-free aerosol fluticasone/salmeterol fluticasone/salmeterol fluticasone/salmeterol, CFC-free aerosol fluticasone/umeclidinium/vilanterol PA folic acid fosamprenavir foscarnet fosinopril fosinopril/hydrochlorothiazide fremanezumab-vfrm PA furosemide galantamine gefitinib PA gemfibrozil gentamicin gentamicin/ acetate gilteritinib fumarate PA glasdegib maleate PA glatiramer PA glecaprevir/pibrentasvir PA glimepiride glipizide glipizide ext-rel glipizide/metformin glucagon nasal powder glucagon, human recombinant glyburide glyburide, micronized glyburide/metformin glycopyrrolate tabs 1 mg, 2 mg granisetron

Appendix F7 12 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs grass mixed pollen extract PA griseofulvin microsize susp, tabs griseofulvin ultramicrosize guaifenesin ext-rel guaifenesin liquid guaifenesin liquid, syrup, tabs guanfacine guanfacine ext-rel halobetasol propionate crm, oint 0.05% heparin homatropine 5% hydralazine hydrochlorothiazide hydrocodone/acetaminophen 5/300 mg, 7.5/300 mg, 10/300 mg hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg hydrocodone/acetaminophen solution 7.5/325 mg/15 mL hydrocodone/homatropine hydrocortisone acetate crm 1% - Lanacort 10 hydrocortisone acetate foam hydrocortisone butyrate crm, oint, soln 0.1% hydrocortisone crm hydrocortisone crm 2.5% hydrocortisone crm, gel, lotion, oint, solution 1% hydrocortisone enema hydrocortisone lotion 1% hydrocortisone oint 0.5% hydrocortisone valerate crm, oint 0.2% hydrocortisone/aloe vera crm 0.5%, 1% hydromorphone hydroxychloroquine hydroxyurea hyoscyamine sulfate ibrutinib PA ibuprofen ibuprofen idelalisib PA

Appendix F7 13 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs imatinib mesylate PA imiquimod indapamide indinavir insulin aspart protamine 70%/insulin aspart 30% insulin glargine insulin human insulin human insulin isophane human insulin isophane human insulin isophane human 70%/regular 30% insulin isophane human 70%/regular 30% insulin lispro insulin lispro insulin lispro protamine/insulin lispro insulin needles insulin syringes interferon alfa-2b PA interferon beta-1a PA interferon beta-1a PA interferon beta-1b PA iodoquinol/hydrocortisone 1-1% ipratropium nasal spray ipratropium nebulization solution ipratropium, CFC-free aerosol ipratropium/albuterol nebulization solution ipratropium/albuterol, CFC-free aerosol irbesartan irbesartan/hydrochlorothiazide isoniazid isosorbide dinitrate oral isosorbide dinitrate/hydralazine isosorbide mononitrate isosorbide mononitrate ext-rel isotretinoin PA isotretinoin - Amnesteem PA isotretinoin - Claravis PA

Appendix F7 14 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs isotretinoin - Myorisan PA isotretinoin - Zenatane PA istradefylline itraconazole ivabradine ivermectin ivosidenib PA ixazomib PA crm 2% ketoconazole shampoo 2% ketoconazole tabs ketorolac ketorolac 0.4% ketorolac 0.5% ketotifen labetalol lactulose soln lamivudine lamivudine lamivudine/tenofovir disoproxil fumarate lamivudine/zidovudine lancets lansoprazole + amoxicillin + clarithromycin lansoprazole delayed-rel caps 15 mg lansoprazole delayed-rel caps 15 mg, 30 mg lanthanum lapatinib PA larotrectinib PA latanoprost leflunomide lenalidomide PA lenvatinib PA letermovir PA leuprolide acetate PA leuprolide acetate PA levalbuterol nebulization solution

Appendix F7 15 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs levalbuterol tartrate, CFC-free aerosol levobunolol levocarnitine 250 mg levocarnitine fumarate 250 mg levocarnitine oral soln 1 gm/10 mL levocetirizine levofloxacin levonorgestrel 1.5 mg levonorgestrel 1.5 mg - My Choice, My Way, Option 2, React, Take Action levonorgestrel releasing IUD levonorgestrel releasing IUD levonorgestrel releasing IUD levonorgestrel releasing IUD levonorgestrel/EE - Trivora levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 - Levora levonorgestrel/EE 0.15/30 and EE 10 levothyroxine levothyroxine - Levoxyl lidocaine crm 4% lidocaine gel 2% lidocaine oint 5% lidocaine patch 4% lidocaine soln 4% lidocaine viscous lidocaine/prilocaine lindane shampoo 1% linezolid susp linezolid tabs liothyronine liraglutide ST lisinopril lisinopril/hydrochlorothiazide lomustine loperamide loperamide lopinavir/ritonavir

Appendix F7 16 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs loratadine liquid, orally disintegrating tabs, tabs loratadine/pseudoephedrine ext-rel lorlatinib PA losartan losartan/hydrochlorothiazide susp 0.5% lovastatin lubiprostone PA magnesium citrate soln malathion maraviroc meclizine meclizine medroxyprogesterone acetate medroxyprogesterone acetate 150 mg/mL mefloquine meloxicam melphalan memantine mercaptopurine mercaptopurine susp PA mesalamine delayed-rel tabs mesalamine delayed-rel tabs ST mesalamine ext-rel caps mesalamine rectal susp mesalamine supp metformin metformin ext-rel 500 mg methadone PA methazolamide methimazole methocarbamol methotrexate methoxsalen oral methylcellulose powder, tabs methyldopa

Appendix F7 17 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs methylergonovine - Methergine metolazone metoprolol succinate ext-rel metoprolol tartrate metoprolol/hydrochlorothiazide metronidazole 250 mg, 375 mg, 500 mg metronidazole crm 0.75% metronidazole gel 0.75% metronidazole gel 1% miconazole miconazole crm 2%, supp 100 mg miconazole crm 4%, supp 200 mg midodrine midostaurin PA minocycline caps minoxidil misoprostol mitotane moexipril crm, lotion, oint 0.1% mometasone spray montelukast morphine ext-rel PA morphine immediate-release morphine oral solution morphine supp moxifloxacin moxifloxacin multivitamins multivitamins drops multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs multivitamins/iron multivitamins/iron drops

Appendix F7 18 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs multivitamins/minerals mupirocin oint 2% mycophenolate mofetil nabumetone nadolol naproxen naproxen sodium naratriptan nateglinide nelfinavir neomycin sulfate tabs neomycin/bacitracin/polymyxin B neomycin/polymyxin B/dexamethasone neomycin/polymyxin B/gramicidin neomycin/polymyxin B/hydrocortisone nepafenac neratinib PA nevirapine nevirapine ext-rel niacin niacin ext-rel nifedipine nifedipine ext-rel nilotinib PA nintedanib PA niraparib PA nisoldipine ext-rel nitrofurantoin ext-rel nitrofurantoin macrocrystals nitrofurantoin susp nitroglycerin lingual spray nitroglycerin oint nitroglycerin sublingual nitroglycerin transdermal /EE - Xulane norethindrone norethindrone acetate

Appendix F7 19 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs norethindrone acetate/EE 1.5/30 norethindrone acetate/EE 1.5/30 and iron norethindrone acetate/EE 1/20 norethindrone acetate/EE 1/20 and iron norethindrone acetate/EE/iron norethindrone/EE norethindrone/EE norethindrone/EE 0.4/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 /EE norgestimate/EE norgestimate/EE 0.25/35 /EE 0.3/30 - Low-Ogestrel nystatin nystatin nystatin/ ofloxacin ofloxacin ofloxacin otic 0.3% olaparib PA olodaterol, CFC-free aerosol omega-3 acid ethyl esters omeprazole delayed-rel caps 20 mg, 40 mg omeprazole delayed-rel tabs 20 mg omeprazole magnesium delayed-rel caps 20 mg omeprazole magnesium delayed-rel tabs 20 mg ondansetron oseltamivir osimertinib PA oxaprozin oxybutynin oxybutynin ext-rel oxycodone concentrate 20 mg/mL oxycodone immediate release oxycodone oral solution 5 mg/5 mL

Appendix F7 20 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs oxycodone/acetaminophen oxycodone/aspirin oxymorphone ext-rel PA palbociclib PA pancrelipase delayed-rel pancrelipase delayed-rel panobinostat PA pantoprazole delayed-rel tabs 20 mg, 40 mg paromomycin pazopanib PA peg 3350/electrolytes peg 3350/electrolytes pegfilgrastim PA peginterferon alfa-2a PA peginterferon beta-1a PA pemigatinib PA penicillin VK pentamidine aerosol pentoxifylline ext-rel permethrin 1% permethrin crm 5% pexidartinib PA phenazopyridine phenobarbital phenytoin phenytoin sodium extended phytonadione pilocarpine pilocarpine tabs pimecrolimus ST pindolol pioglitazone pioglitazone/glimepiride pioglitazone/metformin podofilox solution polyethylene glycol 3350 polymyxin B/bacitracin

Appendix F7 21 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs polymyxin B/trimethoprim polysaccharide iron complex - Nu-Iron 150 polysaccharide iron complex/vitamin B12/folic acid pomalidomide PA ponatinib PA posaconazole oral suspension PA posaconazole tabs PA potassium bicarbonate/potassium citrate effervescent tabs 25 mEq potassium chloride ext-rel potassium chloride liquid potassium chloride powder 20 mEq potassium chloride/potassium bicarbonate/citric acid effervescent tabs 25 mEq potassium citrate ext-rel potassium/sodium phosphates - Phospha 250 Neutral pramipexole prasugrel pravastatin prazosin prednisolone acetate 0.12% prednisolone acetate 1% prednisolone phosphate 1% prednisolone sodium phosphate soln 5 mg/5 mL, 15 mg/5 mL, 25 mg/5 mL prednisolone syrup prenatal vitamins/DHA/docusate/folic acid/polysacc prenatal vitamins/DHA/folic acid prenatal vitamins/docusate/folic acid prenatal vitamins/ferrous fumarate/folic acid prenatal vitamins/folic acid prenatal vitamins/folic acid/omega 3 fatty acids primaquine primidone probenecid procarbazine prochlorperazine , micronized promethazine

Appendix F7 22 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs promethazine supp propafenone propantheline 15 mg propranolol propranolol ext-rel propylthiouracil pseudoephedrine pseudoephedrine ext-rel psyllium caps, powder pyrantel - Reese's Pinworm Medicine pyrazinamide pyridostigmine pyridostigmine ext-rel pyridoxine 25 mg pyrimethamine quinapril quinapril/hydrochlorothiazide rabeprazole tabs 20 mg raltegravir raltegravir ramipril ranolazine ext-rel regorafenib PA repaglinide ribavirin caps, tabs PA ribociclib PA ribociclib + letrozole PA rifabutin rifampin rilpivirine risedronate ritonavir rivastigmine caps, soln rizatriptan ropinirole rucaparib PA

Appendix F7 23 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs ruxolitinib PA sacubitril/valsartan safinamide ST salicylic acid foam 6% salicylic acid liquid 27.5% salicylic acid lotion 6% salicylic acid pad 2% salicylic acid/urea oint 5-10% salmeterol xinafoate ST saquinavir mesylate sargramostim inj sarilumab PA secukinumab PA selegiline caps selenium sulfide lotion 2.5% selinexor PA selumetinib PA semaglutide ST sennosides caps 8.6 mg, syrup 8.8 mg/5 mL, tabs 17.2 mg, 25 m sennosides chew tabs, tabs 15 mg sennosides tabs 8.6 mg sevelamer carbonate sevelamer HCl sharps container sildenafil PA silver sulfadiazine crm 1% simvastatin sirolimus sodium chloride nebulization solution 0.45%, 0.9%, 3%, 6%, 7%, 10% sodium citrate/citric acid sodium fluoride 0.5 mg, 1 mg tabs sodium fluoride chew tabs, drops sodium fluoride crm, gel 1.1% sodium fluoride dental rinse 0.2% sodium fluoride/xylitol chew tabs sodium polystyrene sulfonate oral susp 15 gm/60 mL somatropin PA

Appendix F7 24 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs sonidegib PA sorafenib PA sotalol spacer spironolactone/hydrochlorothiazide stavudine succimer sucralfate sulfacetamide solution 10% sulfacetamide/prednisolone phosphate 10%/0.25% sulfacetamide/sulfur cleanser, crm, foam, lotion, wash 10-5% sulfacetamide/sulfur cleanser, crm, foam, lotion, wash 10-5% sulfacetamide/sulfur crm 10-2% sulfacetamide/sulfur crm 10-2% sulfadiazine sulfamethoxazole/trimethoprim DS sulfasalazine sulfasalazine delayed-rel sulindac sumatriptan sumatriptan inj sumatriptan nasal spray sunitinib PA tacrolimus tacrolimus ST tadalafil PA tafenoquine talazoparib PA tamsulosin tazarotene tazemetostat PA tbo-filgrastim telmisartan/amlodipine telmisartan/hydrochlorothiazide temozolomide PA

Appendix F7 25 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs tenofovir disoproxil fumarate terazosin terbinafine tabs terbutaline terconazole teriparatide PA cypionate testosterone gel testosterone gel 1% tetrabenazine PA tetracycline PA theophylline ext-rel tabs theophylline liquid thioguanine thyroid timolol hemihydrate timolol maleate tinidazole tiotropium tiotropium, CFC-free aerosol tipranavir tizanidine tabs tobramycin oint tobramycin solution tobramycin/dexamethasone susp 0.3%/0.1% tofacitinib PA tofacitinib ext-rel PA tolterodine tolterodine ext-rel topotecan caps PA torsemide tramadol immediate-release tramadol/acetaminophen trametinib PA

Appendix F7 26 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs trandolapril trandolapril/verapamil ext-rel tranexamic acid treprostinil PA treprostinil PA tretinoin caps tretinoin crm, gel crm 0.5% triamcinolone acetonide crm, lotion 0.025% triamcinolone acetonide crm, lotion, oint 0.1% triamcinolone acetonide spray triamcinolone paste triamterene triamterene/hydrochlorothiazide 37.5/25 triamterene/hydrochlorothiazide 37.5/25 triamterene/hydrochlorothiazide 75/50 trifluridine trifluridine/tipiracil PA trimethoprim tabs trospium trospium ext-rel tucatinib PA umeclidinium/vilanterol ST urea crm 10% urea crm 20% urea lotion 10% ursodiol ursodiol valacyclovir valganciclovir oral solution valganciclovir tabs valsartan valsartan/amlodipine ST valsartan/amlodipine/hydrochlorothiazide ST valsartan/hydrochlorothiazide vancomycin vancomycin oral soln

Appendix F7 27 Appendix F7. Priority Partners (Priority) Prescription Drugs Subject to NQTLs, by Delivery System

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs vandetanib PA vemurafenib PA venetoclax PA verapamil ext-rel verapamil ext-rel vismodegib PA vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid vitamin E vorapaxar vorinostat PA warfarin zanamivir zanubrutinib PA zidovudine acetate zolmitriptan zolmitriptan orally disintegrating tabs

Appendix F7 28