Appendix F6. Medstar Family Choice (Medstar) Prescription Drugs Subject to Nqtls, by Delivery System

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Appendix F6. Medstar Family Choice (Medstar) Prescription Drugs Subject to Nqtls, by Delivery System Appendix F6. MedStar Family Choice (MedStar) Prescription Drugs Subject to NQTLs, by Delivery System Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Eucrisa 2 % topical ointment N Y ciclopirox 0.77 % topical cream N Y ciclopirox 0.77 % topical suspension N Y Sklice 0.5 % lotion N Y Bethkis 300 mg/4 mL solution for nebulization Y N Gralise 300 mg tablet,extended release Y N Gralise 30-Day Starter Pack 300 mg (9)-600 mg (69) tablet, Y N ext. release Gralise 600 mg tablet,extended release Y N Esbriet 267 mg capsule Y N Esbriet 267 mg tablet Y N Esbriet 801 mg tablet Y N Ofev 100 mg capsule Y N Ofev 150 mg capsule Y N Nucala 100 mg subcutaneous solution Y N Juxtapid 10 mg capsule Y N Juxtapid 20 mg capsule Y N Juxtapid 5 mg capsule Y N Lovaza 1 gram capsule Y N Aimovig Autoinjector 140 mg/mL subcutaneous auto- Y N injector Aimovig Autoinjector 70 mg/mL subcutaneous auto-injector Y N Alecensa 150 mg capsule Y N Alunbrig 30 mg tablet Y N Balversa 3 mg tablet Y N Balversa 4 mg tablet Y N Balversa 5 mg tablet Y N Bosulif 100 mg tablet Y N Bosulif 400 mg tablet Y N Bosulif 500 mg tablet Y N Braftovi 50 mg capsule Y N Cabometyx 20 mg tablet Y N Appendix F6 1 Appendix F6. MedStar Family Choice (MedStar) Prescription Drugs Subject to NQTLs, by Delivery System Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Cabometyx 40 mg tablet Y N Cabometyx 60 mg tablet Y N Cometriq 100 mg/day (80 mg x 1-20 mg x 1) capsules Y N Cometriq 140 mg/day (80 mg x 1-20 mg x 3) capsules Y N Cometriq 60 mg/day (20 mg x 3/day) capsules Y N Cotellic 20 mg tablet Y N Eligard 22.5 mg (3 month) subcutaneous syringe Y N Eligard 30 mg (4 month) subcutaneous syringe Y N Eligard 45 mg (6 month) subcutaneous syringe Y N Eligard 7.5 mg (1 month) subcutaneous syringe Y N Erwinaze 10,000 unit solution for injection Y N Hycamtin 0.25 mg capsule Y N Hycamtin 1 mg capsule Y N Ibrance 100 mg capsule Y N Ibrance 125 mg capsule Y N Ibrance 75 mg capsule Y N Iclusig 15 mg tablet Y N Iclusig 45 mg tablet Y N Imbruvica 140 mg capsule Y N Imbruvica 140 mg tablet Y N Imbruvica 280 mg tablet Y N Imbruvica 420 mg tablet Y N Imbruvica 560 mg tablet Y N Imbruvica 70 mg capsule Y N Jakafi 10 mg tablet Y N Jakafi 15 mg tablet Y N Jakafi 20 mg tablet Y N Jakafi 25 mg tablet Y N Jakafi 5 mg tablet Y N Kymriah 0.6 x 10exp8 to 6 x10exp8 cell intravenous Y N suspension leuprolide 1 mg/0.2 mL subcutaneous kit Y N Appendix F6 2 Appendix F6. MedStar Family Choice (MedStar) Prescription Drugs Subject to NQTLs, by Delivery System Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Libtayo 50 mg/mL intravenous solution Y N Lorbrena 25 mg tablet Y N Lumoxiti 1 mg intravenous solution Y N Lupron Depot (6 Month) 45 mg intramuscular syringe kit Y N Lupron Depot 11.25 mg (3 month) intramuscular syringe kit Y N Lupron Depot 22.5 mg (3 month) intramuscular syringe kit Y N Lupron Depot 3.75 mg intramuscular syringe kit Y N Lupron Depot 30 mg (4 month) intramuscular syringe kit Y N Lupron Depot 7.5 mg intramuscular syringe kit Y N Lupron Depot-Ped 11.25 mg (3 month) intramuscular Y N syringe kit Lupron Depot-Ped 11.25 mg intramuscular kit Y N Lupron Depot-Ped 15 mg intramuscular kit Y N Lupron Depot-Ped 7.5 mg (Ped) intramuscular kit Y N Mekinist 0.5 mg tablet Y N Mekinist 2 mg tablet Y N Mektovi 15 mg tablet Y N Nubeqa 300 mg tablet Y N Piqray 200 mg/day (200 mg x 1) tablet Y N Polivy 140 mg intravenous solution Y N Rozlytrek 100 mg capsule Y N Stivarga 40 mg tablet Y N Synribo 3.5 mg subcutaneous solution Y N Tafinlar 50 mg capsule Y N Tafinlar 75 mg capsule Y N Tagrisso 40 mg tablet Y N Tagrisso 80 mg tablet Y N Talzenna 0.25 mg capsule Y N Tarceva 100 mg tablet Y N Tarceva 150 mg tablet Y N Tarceva 25 mg tablet Y N Tasigna 150 mg capsule Y N Appendix F6 3 Appendix F6. MedStar Family Choice (MedStar) Prescription Drugs Subject to NQTLs, by Delivery System Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Tasigna 200 mg capsule Y N Tasigna 50 mg capsule Y N Tibsovo 250 mg tablet Y N Turalio 200 mg capsule Y N Tykerb 250 mg tablet Y N Venclexta 10 mg tablet Y N Venclexta 100 mg tablet Y N Venclexta 50 mg tablet Y N Venclexta Starting Pack 10 mg-50 mg-100 mg tablets in a Y N dose pack Vizimpro 15 mg tablet Y N Vizimpro 30 mg tablet Y N Vizimpro 45 mg tablet Y N Xalkori 200 mg capsule Y N Xalkori 250 mg capsule Y N Xospata 40 mg tablet Y N Xpovio 160 mg/week (20 mg x 8) tablet Y N Zelboraf 240 mg tablet Y N Zoladex 10.8 mg subcutaneous implant Y N Zoladex 3.6 mg subcutaneous implant Y N Zydelig 100 mg tablet Y N Zydelig 150 mg tablet Y N Zykadia 150 mg tablet Y N Cutaquig 16.5 % subcutaneous solution Y N pretomanid 200 mg tablet Y N Sirturo 100 mg tablet Y N Noxafil 100 mg tablet,delayed release Y N Noxafil 200 mg/5 mL (40 mg/mL) oral suspension Y N Synjardy 12.5 mg-1,000 mg tablet Y N Tavalisse 150 mg tablet Y N Prolia 60 mg/mL subcutaneous syringe Y N Xgeva 120 mg/1.7 mL (70 mg/mL) subcutaneous solution Y N Appendix F6 4 Appendix F6. MedStar Family Choice (MedStar) Prescription Drugs Subject to NQTLs, by Delivery System Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Amitiza 24 mcg capsule Y N Amitiza 8 mcg capsule Y N Nourianz 20 mg tablet Y N Nourianz 40 mg tablet Y N Xyrem 500 mg/mL oral solution Y N Firazyr 30 mg/3 mL subcutaneous syringe Y N Kalbitor 10 mg/mL (1 mL) subcutaneous solution Y N Lo Loestrin Fe 1 mg-10 mcg (24)/10 mcg (2) tablet Y N Minastrin 24 Fe 1 mg-20 mcg (24)/75 mg (4) chewable Y N tablet Natazia 3 mg/2 mg-2 mg/2 mg-3 mg/1 mg tablet Y N Orkambi 100 mg-125 mg oral granules in packet Y N Orkambi 100 mg-125 mg tablet Y N Orkambi 150 mg-188 mg oral granules in packet Y N Orkambi 200 mg-125 mg tablet Y N Kalydeco 150 mg tablet Y N Kalydeco 50 mg oral granules in packet Y N Kalydeco 75 mg oral granules in packet Y N Pulmozyme 1 mg/mL solution for inhalation Y N Endari 5 gram oral powder packet Y N Linzess 145 mcg capsule Y N Linzess 290 mcg capsule Y N Linzess 72 mcg capsule Y N Movantik 12.5 mg tablet Y N Movantik 25 mg tablet Y N Mavyret 100 mg-40 mg tablet Y N deferasirox 125 mg dispersible tablet Y N Doptelet (30 tab pack) 20 mg tablet Y N desmopressin 10 mcg/spray (0.1 mL) nasal spray Y N Jivi 1,000 (+/-) unit intravenous solution Y N Stimate 150 mcg/spray (0.1 mL) nasal spray Y N Mayzent 0.25 mg tablet Y N Appendix F6 5 Appendix F6. MedStar Family Choice (MedStar) Prescription Drugs Subject to NQTLs, by Delivery System Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Mayzent 2 mg tablet Y N Mayzent Starter Pack 0.25 mg (12 tabs) tablets Y N Fasenra 30 mg/mL subcutaneous syringe Y N Nucala 100 mg/mL subcutaneous auto-injector Y N Nucala 100 mg/mL subcutaneous syringe Y N Synagis 100 mg/mL intramuscular solution Y N Duragesic 50 mcg/hr transdermal patch Y N fentanyl 100 mcg/hr transdermal patch Y N fentanyl 12 mcg/hr transdermal patch Y N fentanyl 25 mcg/hr transdermal patch Y N fentanyl 37.5 mcg/hour transdermal patch Y N fentanyl 50 mcg/hr transdermal patch Y N fentanyl 62.5 mcg/hour transdermal patch Y N fentanyl 75 mcg/hr transdermal patch Y N fentanyl 87.5 mcg/hour transdermal patch Y N methadone 10 mg tablet Y N methadone 10 mg/5 mL oral solution Y N methadone 5 mg tablet Y N morphine ER 100 mg capsule,extended release pellets Y N morphine ER 100 mg tablet,extended release Y N morphine ER 15 mg tablet,extended release Y N morphine ER 200 mg tablet,extended release Y N morphine ER 30 mg capsule,extended release pellets Y N morphine ER 30 mg tablet,extended release Y N morphine ER 60 mg capsule,extended release pellets Y N morphine ER 60 mg tablet,extended release Y N Dificid 200 mg tablet Y N Ampyra 10 mg tablet,extended release Y N Onpattro 2 mg/mL intravenous solution Y N Repatha Pushtronex 420 mg/3.5 mL subcutaneous Y N wearable injector Repatha SureClick 140 mg/mL subcutaneous pen injector Y N Appendix F6 6 Appendix F6.
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