Appendix F10. Fee-for-Service Program (MH, SUD, M/S) Prescription Drugs Subject to NQTLs, by Delivery System

Categories Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs Abilify Maintena X X X Abilify MyCite X X X Adasuve X X X Adhansia XR X X Adzenys XR ODT X X X X amoxapine X amphetamine X X amphetamine ER suspension (Adzenys ER) X X amphetamine salt combo (Adderall) X X amphetamine salt combo ER (Adderall XR) X X amphetamine sulfate (Evekeo) X X Aplenzin X X Aptensio XR X X Aptiom X aripiprazole (Abilify) X X X aripiprazole ODT (Abilify Discmelt) X X X Aristada X X X Aristada ER X X X Aristada Initio X X X armodafinil (Nuvigil) X X atomoxetine (Strattera) X X X Austedo X X X Banzel X X Belsomra X X X benztropine (Cogentin) X Briviact (multiple formulations) X X XL (Forfivo XL) X X bupropion, bupropion SR, bupropion XL (Welbutrin, Wellbutrin SR, Wellbutrin XL) X X Caplyta X ER (Carbatol ER) X carbamazepine suspension (Tegretol) (generic only) X X carbamazepine XR (Tegretol XR) X X carbmazepine (Tegretol) X Celontin X X hydrate X X chlorpromazine (Thorazine) X X tablets, solution (Celexa) X clobazam suspension (Onfi) X X X clobazam tablets (Onfi) X X X X (Klonopin) X clonazepam ODT (Klonopin ODT) X X (Catapres) X X X clonidine ER (Kapvay ER) X X X

Appendix F10 1 Appendix F10. Fee-for-Service Program (MH, SUD, M/S) Prescription Drugs Subject to NQTLs, by Delivery System

Categories Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs X clozapine (Clorazil) X X X clozapine ODT (Fazaclo) X X X Clozaril X X X Cotempla X X Cotempla XR OCT X X Daytrana X X Depo-Provera (mulitple formulations) X X X desipramine X desvenlafaxine ER (Khedezla, Pristiq) X X desvenlafaxine fumarate ER X X dexmethylphenidate tablets (Focalin) X X dexmethylphenidate XR (Focalin XR) (generic only) X X dextroamphetamine capsules (Dexedrine ER) X X dextroamphetamine solution (Procentra) X X Diacomit capsules, powder pack X X X diazepam rectal (Diastat, Acudial) X divalproex sprinkles (Depakote sprinkles) X divalproex, divalproex ER (Depakote, Depakote ER) X (Silenor) X X droperidol X (Cymbalta) X X X Dyanavel XR X X Edluar X X Eligard (multiple formulations) (leuprolide acetate) X X X Emsam X X X Epidiolex X X X Equetro X X solution (Lexapro) X X escitalopram tablets (Lexapro) X (ProSom) X X (Lunesta) X X X (Zarontin) X X Evekeo X X Evekeo ODT X X Fanapt X X X (Felbatol) X X Fetzima X X capsules 60mg X X fluoxetine capsules, solution (all strengths except 60mg) (Prozac) X fluoxetine tablets (Sarafem) X X fluoxetine weekly (Prozac weekly) X X fluphenazine (Prolixin) X X fluphenazine decanoate inj (Prolixin Decanoate Inj) X X (Dalmane) X X (Luvox) X

Appendix F10 2 Appendix F10. Fee-for-Service Program (MH, SUD, M/S) Prescription Drugs Subject to NQTLs, by Delivery System

Categories Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs fluvoxamine ER (Luvox CR) X X Focalin XR (Brand only) X X Fycompa X X capsules, tablets (Neurontin) X gabapentin solution (Neurotin) X X Gabitril (Brand only) X Geodon IM X X X (Tenex) X X X guanfacine ER (Intuniv ER) X X X haloperidol (Haldol) X X haloperidol decanoate inj (Haldol Decanoate IM) X X Hetlioz X X Horizant X X (multiple formulations) X imipramine X Ingrezza (multiple formuations) X X X Intuniv ER X X X Invega Sustenna X X Invega Trinza X X X Jornay PM X X Kapvay 0.1-0.2mg Dose Pack X X X Lamictal XR dose pack X X (Lamictal) X lamotrigine dose pack X X lamotrigine ODT (Lamictal ODT) X X lamotrigine XR (Lamictal XR) X X Latuda X X X leuprolide acetate X X X ER (Keppra XR) X X levetiracetam tablets, solution (Keppra) X liothyronine (Triostat) X X X lithium (multiple formulations) X X X (multiple formulations) X loxapine X X loxapine capsules (Loxitane) X X Lupron 3.75mg (leuprolide acetate) X X X Lupron Depot (multiple formuations) (leuprolide acetate) X X X maprotiline X Marplan X X X methamphetamine (Desoxyn) X X methylphenidate CD capsules (Metadate CD) X X methylphenidate chewable (Methylin chewable) X X methylphenidate CR tablets (except 72mg) (Concerta) X X methylphenidate CR tablets 72mg X X methylphenidate ER capsules (Ritalin LA) X X methylphenidate ER tablets (Ritalin SR) X X

Appendix F10 3 Appendix F10. Fee-for-Service Program (MH, SUD, M/S) Prescription Drugs Subject to NQTLs, by Delivery System

Categories Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs methylphenidate oral solution (Methylin) X X methylphenidate tablets (Ritalin) X X X X X , mirtazapine ODT (Remeron, Remeron ODT) X modafinil X X molindone X X Mydayis X X Mydayis ER X X Nayzilam X X (Serzone) X X Northera X X nortriptyline X Nuplazid X X X IM (Zyprexa IM) X X olanzapine ODT (Zyprexa Zydis) X X olanzapine tablets (Zyprexa) X X olanzapine/fluoxetine (Symbyax) X X X X tablets, suspension (Trileptal) X Oxtellar XR X X paliperidone (Invega) X X X (Paxil) X paroxetine 7.5mg capsules (Brisdelle) X X paroxetine CR (Paxil CR) X Paxil suspension X X Peganone X X perphenazine (Trilafon) X X perphenazine/amitriptyline (Triavil) X X Perseris X X X Pexeva X X (Nardil) X X X , phenytoin ER (Dilantin, Dilantin Infatabs, Phenytek) X pimozide (Orap) X X capsules (Lyrica) X X pregabalin solution (Lyrica) X X (Mysoline) X protriptyline X quetiapine (Seroquel) X X quetiapine ER (Seroquel XR) X X Quillichew ER X X Quillivant XR X X ramelteon (Rozerem) X X Rexulti X X X Risperdal Consta X X X rispreridone, risperidone ODT (Risperdal) X X Rozerem X X

Appendix F10 4 Appendix F10. Fee-for-Service Program (MH, SUD, M/S) Prescription Drugs Subject to NQTLs, by Delivery System

Categories Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs Sabril powder pack, tablets (Brand only) X Saphris X X X Secuado X X X tablets, concentrated solution (Zoloft) X Silenor X X Spravato X X X Spritam X X Strattera X X X Sunosi X X Sympazan X X X Tegretol suspension (Brand only) X 15mg, 30mg (Restoril) X temazepam 7.5mg, 22.5mg X X thioridazine (Mellaril) X X thiothixene (Navane) X X (Gabitril) (generic only) X X (Topamax) X topiramate ER (Qudexy ER) X X X topiramate sprinkles (Topamax sprinkles) X tranylcypromine (Parnate) X X (Desyrel) X X (Halcion) X X trifluoperazine (Stelazine) X X trihexyphenidyl X X Trintellix X X Trokendi XR X X valproic acid (Depakene) X (Effexor) X venlafaxine ER capsules (Effexor XR) X venlafaxine ER tablets X X Versacloz X X X (multiple formulations) X X Viibryd X X Vimpat X X Vraylar X X X Vyvanse X X Vyvanse chewable tablets X X Wakix X X Xyrem X X X (Sonata) X X Zenzedi X X ziprasidone (Geodon) X X ziprasidone IM (Geodon IM) X X (Ambien) X X zolpidem ER (Ambien CR) X X zolpidem SL (Intermezzo) X X Zolpimist X X

Appendix F10 5 Appendix F10. Fee-for-Service Program (MH, SUD, M/S) Prescription Drugs Subject to NQTLs, by Delivery System

Categories Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs MH Drugs SUD Drugs Med/Surg Drugs (Zonegran) X Zulresso X X Zyban SR X X Zyprexa Relprevv X X X acamprosate (Campral) X X X Bunavail X X buprenorphine (Subutex) X X buprenorphine/naloxone film (Suboxone) (generic only) X X buprenorphine/naloxone tablets (Suboxone) X X bupropion SR (Zyban SR) X X bupropion, bupropion SR, bupropion XL (Wellbutrin, Wellbutrin SR, Wellbutrin XL) X Campral X X X Chantix X X disulfiram (Antabuse) X X X Evzio X X X Lucemyra X X Methadone X X X naloxone (Narcan) X naltrexone (Revia) X X X Narcan nasal spray X gum X X Nicotine lozenge X X Nicotine patches X X Nicotrol nasal spray, inhaler X X X Sublocade X X X Suboxone film (Brand only) X X Subutex X X X Vivitrol X X X Zubsolv X X Cinryze X X X Spinraza X X X Zolgensma X X X

Appendix F10 6