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Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Formulary Med/Surg Drugs Med/Surg Drugs -PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG CITRATE TAB 20 MG (BASE EQUIVALENT) PROGESTERONE MICRONIZED CAP 100 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML Y CALCIUM CITRATE-VITAMIN D TAB 250 MG-200 UNIT (ELEMENTAL CA) PANCRELIPASE (LIP-PROT-AMYL) DR CAP 12000-38000-60000 UNIT *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG HCL (SLEEP) TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** LEUCOVORIN CALCIUM TAB 10 MG *ADHESIVE BANDAGES*** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *MULTIPLE VITAMINS W/ MINERALS TAB** BISACODYL SUPPOS 10 MG CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT) LAMIVUDINE TAB 150 MG NORETHINDRONE ACETATE-ETHINYL TAB 1 MG-5 MCG NADOLOL TAB 80 MG NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR *LACTOBACILLUS CAP** *ADHESIVE BANDAGES*** *MULTIPLE VITAMIN TAB** *SPECIALITY VITAMIN PRODUCT TAB** NYSTATIN TOPICAL POWDER 100000 UNIT/GM PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG *ADHESIVE BANDAGES*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *ADHESIVE BANDAGES*** LIDOCAINE PATCH 4%

Appendix F9 1 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DOCUSATE SODIUM CAP 50 MG *MULTIPLE VITAMIN TAB** FREMANEZUMAB-VFRM SUBCUTANEOUS SOLN PREF SYR 225 MG/1.5ML Y *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** *MULTIPLE VITAMINS W/ MINERALS TAB** DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMIN TAB** UREA CREAM 40% *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML*** SIMETHICONE CHEW TAB 125 MG ASPIRIN TAB 325 MG *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** BISACODYL TAB DELAYED RELEASE 5 MG TENOFOVIR DISOPROXIL FUMARATE TAB 200 MG *ADHESIVE BANDAGES*** *LANCETS*** LEFLUNOMIDE TAB 10 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** TAB 10 MG FUROSEMIDE TAB 80 MG IBUPROFEN CHEW TAB 100 MG GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *VITAMINS W/ LIPOTROPICS TAB** POTASSIUM CHLORIDE CAP ER 8 MEQ ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML Y ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML Y OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML) Y

Appendix F9 2 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** LOSARTAN POTASSIUM TAB 50 MG LAMIVUDINE ORAL SOLN 10 MG/ML CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM POVIDONE-IODINE OINT 10% *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML*** ACETAMINOPHEN SUSP 160 MG/5ML *LANCETS*** ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE SUSP 508-475 MG/10ML SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT) Y FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT *ADHESIVE BANDAGES*** *LANCETS*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML*** FLUTICASONE PROPIONATE HFA INHAL AER 220 MCG/ACT (250/VALVE) CAPSAICIN CREAM 0.035% PROPAFENONE HCL CAP ER 12HR 425 MG DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP CLOTRIMAZOLE CREAM 1% *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMIN TAB** DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG CALCIUM TAB 500 MG CHLORHEXIDINE GLUCONATE DRESSING NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG *VITAMINS W/ LIPOTROPICS TAB** NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL PF OP SOLN 0.4-0.3% TRETINOIN CREAM 0.025% Y SIMETHICONE CHEW TAB 80 MG

Appendix F9 3 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG *ADHESIVE BANDAGES*** PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV) ACETAMINOPHEN DISINTEGRATING TAB 80 MG ACETAMINOPHEN DISINTEGRATING TAB 160 MG INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (50-50) *MULTIPLE VITAMINS W/ MINERALS TAB** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML CHOLECALCIFEROL DROPS 10 MCG/0.028ML (400 UNIT/0.028ML) INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG PYRIDOSTIGMINE BROMIDE TAB 60 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** DIPHENHYDRAMINE HCL CAP 50 MG *MULTIPLE VITAMIN LIQUID** TAB 100 MCG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG NAPROXEN SODIUM TAB 220 MG PSEUDOEPHEDRINE W/ DM-GG LIQUID 30-10-100 MG/5ML GLIMEPIRIDE TAB 4 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 12 MG** *URINE GLUCOSE-KETONES TEST STRIPS*** GLYCERIN-HYPROMELLOSE-PEG 400 OPHTH SOLN 0.2-0.2-1% BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 40 MCG/ACT *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** BISMUTH SUBSALICYLATE CHEW TAB 262 MG *ADHESIVE BANDAGES*** ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV) MISOPROSTOL TAB 200 MCG PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 120-1200 MG CALCIUM & PHOSPHORUS W/ VITAMIN D TAB 105 MG-81 MG-120 UNIT

Appendix F9 4 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ASPIRIN CHEW TAB 81 MG CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) CLINDAMYCIN HCL CAP 300 MG *LANCETS*** MICONAZOLE NITRATE VAGINAL CREAM 2% CARVEDILOL TAB 3.125 MG INTERFERON ALFA-2B INJ 10000000 UNIT/ML Y LEUPROLIDE ACETATE (4 MONTH) FOR SUBCUTANEOUS INJ KIT 30 MG Y CHLORHEXIDINE GLUCONATE SOLN 4% CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV) CLOTRIMAZOLE CREAM 1% WATER FOR INJECT, BACTERIOSTATIC BENZYL CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML ASPIRIN TAB DELAYED RELEASE 325 MG ELEXACAF-TEZACAF-IVACAF 100-50-75 MG &IVACAFTOR 150 MG TBPK Y CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) CALCIUM TAB 600 MG FUROSEMIDE ORAL SOLN 8 MG/ML POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM BISMUTH SUBSALICYLATE SUSP 262 MG/15ML NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG CELECOXIB CAP 400 MG Y CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LANCETS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *LANCETS*** *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** *LANCETS*** ERTUGLIFLOZIN-METFORMIN HCL TAB 7.5-1000 MG Y FOLIC ACID TAB 400 MCG

Appendix F9 5 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LACTOBACILLUS TAB** POTASSIUM CITRATE TAB ER 5 MEQ (540 MG) CEFADROXIL CAP 500 MG PANCRELIPASE (LIP-PROT-AMYL) TAB 10440-39150-39150 UNIT CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) SENNOSIDES TAB 8.6 MG SODIUM FLUORIDE CREAM 1.1% POTASSIUM BICARBONATE EFFER TAB 25 MEQ *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** RILPIVIRINE HCL TAB 25 MG (BASE EQUIVALENT) *BIOFLAVONOID PRODUCTS TAB ER** LATANOPROST OPHTH SOLN 0.005% MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV) LACTULOSE SOLUTION 10 GM/15ML *LANCETS*** NAPROXEN TAB EC 375 MG DOCUSATE SODIUM CAP 50 MG IBUPROFEN TAB 200 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG TAB 100 MG -PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG PRAZOSIN HCL CAP 2 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT *MULTIPLE VITAMIN TAB** *LANCETS*** *MULTIPLE URINE TEST STRIPS*** DARUNAVIR ETHANOLATE TAB 75 MG (BASE EQUIV) BETHANECHOL CHLORIDE TAB 50 MG PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM PROPRANOLOL HCL ORAL SOLN 20 MG/5ML

Appendix F9 6 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG FOLIC ACID TAB 1 MG *SPECIALITY VITAMIN PRODUCT TAB** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML CHLORPHENIRAMINE MALEATE TAB 4 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG*** BENZOYL PEROXIDE GEL 10% ERGOCALCIFEROL TAB 50 MCG (2000 UNIT) *RESPIRATORY THERAPY SUPPLIES - MISC** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG SALINE NASAL SPRAY 0.65% LENVATINIB CAP THER PACK 2 X 10 MG & 4 MG (24 MG DAILY DOSE) Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *RESPIRATORY THERAPY SUPPLIES - MISC** *MULTIPLE VITAMIN CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** LEVONORGESTREL TAB 1.5 MG *B-COMPLEX W/ MINERALS TAB** *ADHESIVE BANDAGES*** INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT/ML (75-25) LEVOCARNITINE (DIETARY) ORAL SOLN 1 GM/10ML INSULIN LISPRO INJ 100 UNIT/ML *B-COMPLEX W/ C & FOLIC ACID TAB*** BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% *LACTOBACILLUS CAP**

Appendix F9 7 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** ASPIRIN CHEW TAB 81 MG LOMUSTINE CAP 10 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** *LANCETS*** CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG BACITRACIN ZINC OINT 500 UNIT/GM FLUOROURACIL CREAM 5% CARBOXYMETHYLCELLULOSE-GLYCERIN (PF) OPHTH SOLN 0.5-0.9% IVABRADINE HCL TAB 5 MG (BASE EQUIV) ALMOND OIL (SWEET) ASPIRIN TAB 325 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LANCETS*** DEXAMETHASONE TAB 0.75 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *B-COMPLEX W/ C CAP** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *B-COMPLEX W/ FOLIC ACID TAB ER** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT NINTEDANIB ESYLATE CAP 150 MG (BASE EQUIVALENT) Y ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML CETIRIZINE HCL TAB 5 MG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG BENZOYL PEROXIDE CREAM 10% DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG FENOFIBRATE MICRONIZED CAP 67 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 8 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/ IRON SOLN** INTERFERON BETA-1A SOLN PREF SYR 44 MCG/0.5ML (24MU/ML) Y ACETAMINOPHEN CHEW TAB 500 MG NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG SENNOSIDES LIQUID 8.8 MG/ML *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS LIQUID** CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) SIMETHICONE CHEW TAB 125 MG CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) BISMUTH SUBSALICYLATE SUSP 262 MG/15ML *LACTOBACILLUS BIFIDUS CAP** FENOFIBRATE TAB 160 MG BISACODYL SUPPOS 10 MG TOLNAFTATE AEROSOL POW 1% DIPHENHYDRAMINE HCL TAB 25 MG IPRATROPIUM BROMIDE NASAL SOLN 0.06% (42 MCG/SPRAY) EPLERENONE TAB 25 MG LAROTRECTINIB SULFATE CAP 100 MG (BASE EQUIVALENT) Y NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR *MULTIPLE VITAMIN TAB** PROPYLENE GLYCOL OPHTH SOLN 0.6% INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG) ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** SALINE NASAL SPRAY 0.65% INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") HYOSCYAMINE SULFATE TAB DISINT 0.125 MG CAPECITABINE TAB 500 MG Y

Appendix F9 9 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALENDRONATE SODIUM TAB 35 MG TERIFLUNOMIDE TAB 7 MG Y CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLN 0.5% SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML SIMETHICONE SUSP 40 MG/0.6ML AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CAP** SIMETHICONE SUSP 40 MG/0.6ML *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** PREDNISONE TAB THERAPY PACK 10 MG (21) ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV) Y *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** PREDNISONE TAB 1 MG MELOXICAM TAB 7.5 MG BENZOYL PEROXIDE CREAM 10% PREDNISONE TAB THERAPY PACK 10 MG (48) CARVEDILOL TAB 6.25 MG *ARTIFICIAL TEAR OPHTH SOLUTION*** CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** LUMACAFTOR-IVACAFTOR TAB 100-125 MG Y *OMEGA-3 FATTY ACIDS CAP 1400 MG** IPRATROPIUM BROMIDE INHAL SOLN 0.02% *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** BISMUTH SUBSALICYLATE SUSP 525 MG/15ML CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-600 UNIT CHLORHEXIDINE GLUCONATE SOLN 4% *MULTIPLE VITAMINS W/ MINERALS TAB** MICONAZOLE NITRATE VAGINAL SUPP 1200 MG & 2% CREAM KIT *MULTIPLE VITAMINS W/ MINERALS TAB** LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG

Appendix F9 10 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** NALOXEGOL OXALATE TAB 12.5 MG (BASE EQUIVALENT) HYDROCORTISONE VALERATE OINT 0.2% ALOGLIPTIN-PIOGLITAZONE TAB 12.5-45 MG *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** MELATONIN SL TAB 10 MG PERMETHRIN AEROSOL 0.5% CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ASPIRIN TAB DELAYED RELEASE 81 MG *ALCOHOL SWABS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** BENZOYL PEROXIDE GEL 8% IVABRADINE HCL ORAL SOLN 5 MG/5ML (BASE EQUIV) METOPROLOL TAB 100 MG *B-COMPLEX VITAMIN TAB ER** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *ADHESIVE BANDAGES*** POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS TAB** THEOPHYLLINE ELIXIR 80 MG/15ML NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG STAVUDINE CAP 15 MG GUAIFENESIN TAB ER 12HR 600 MG *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** DARUNAVIR-COBIC-EMTRICITAB-TENOFOV AF TAB 800-150-200-10 MG CEPHALEXIN FOR SUSP 250 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 11 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML) Y *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** NEVIRAPINE TAB ER 24HR 100 MG *B-COMPLEX W/ ZINC LIQ** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *LANCETS*** *VITAMIN D & K TAB*** ONDANSETRON HCL TAB 8 MG MORPHINE SULFATE TAB 15 MG Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") CEFPROZIL FOR SUSP 250 MG/5ML *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS CAP** *ALCOHOL SWABS*** NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG FENOFIBRATE TAB 48 MG CHLORPHENIRAMINE MALEATE TAB 4 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** LIDOCAINE PATCH 4% CALCIUM CARBONATE-VITAMIN D CAP 600 MG-200 UNIT NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG DISOPYRAMIDE CAP 100 MG CYCLOSPORINE MODIFIED CAP 25 MG AMOXICILLIN (TRIHYDRATE) CAP 500 MG EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT Y METRONIDAZOLE VAGINAL GEL 0.75% CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) PROPRANOLOL HCL TAB 20 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 12 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** GUAIFENESIN TAB 400 MG THEOPHYLLINE CAP ER 24HR 200 MG *ALCOHOL SWABS*** *LANCETS*** *BIOFLAVONOID PRODUCTS TAB** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** ALMOND OIL (SWEET) CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE *LANCETS*** *ALCOHOL SWABS*** ACETAMINOPHEN SUSP 160 MG/5ML LENALIDOMIDE CAP 5 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML Y DESOXIMETASONE OINT 0.25% INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *ALCOHOL SWABS*** DOCUSATE CALCIUM CAP 240 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") NONOXYNOL-9 GEL 4% INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *LANCETS*** *MULTIPLE VITAMIN TAB** *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** NITROGLYCERIN CAP ER 6.5 MG *ADHESIVE BANDAGES - PADS*** TAB 20 MG LEVOTHYROXINE SODIUM TAB 25 MCG SALINE NASAL SPRAY 0.65% DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML

Appendix F9 13 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LEVOTHYROXINE SODIUM TAB 150 MCG POTASSIUM CHLORIDE TAB ER 20 MEQ (1500 MG) *LANCETS*** CABERGOLINE TAB 0.5 MG LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG CONDOMS LATEX LUBRICATED *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** *LANCETS*** -DM SYRUP 6.25-15 MG/5ML *LANCETS*** DILTIAZEM HCL CAP ER 24HR 120 MG *B-COMPLEX VITAMIN CAP** VERAPAMIL HCL CAP ER 24HR 100 MG FLUTICASONE PROPIONATE AER POW BA 50 MCG/BLISTER CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV) HYDROCORTISONE LOTION 1% CELECOXIB CAP 200 MG Y ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLN 0.5% INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 100 MCG/0.5ML Y POVIDONE-IODINE SOLN 10% NADOLOL TAB 40 MG INSULIN LISPRO PROTAMINE & LISPRO INJ 100 UNIT/ML (50-50) FENTANYL TD PATCH 72HR 12 MCG/HR Y DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML GUAIFENESIN LIQUID 100 MG/5ML BISMUTH SUBSALICYLATE SUSP 262 MG/15ML CYPIONATE IM INJ IN OIL 100 MG/ML Y DIPHENHYDRAMINE HCL CAP 25 MG SUMATRIPTAN SUCCINATE SOLUTION PREFILLED SYRINGE 6 MG/0.5ML PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG

Appendix F9 14 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LACTOBACILLUS TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05% NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG POTASSIUM BICARBONATE EFFER TAB 25 MEQ FLUOCINOLONE ACETONIDE CREAM 0.025% DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) LEUCOVORIN CALCIUM TAB 15 MG ASPIRIN TAB DELAYED RELEASE 81 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML*** CETIRIZINE HCL TAB 10 MG SALINE NASAL AEROSOL SOLN 0.9% FLUTICASONE PROPIONATE AER POW BA 250 MCG/BLISTER GLIPIZIDE TAB 5 MG *BACITRACIN-POLYMYXIN B OINT*** TENOFOVIR DISOPROXIL FUMARATE TAB 150 MG GUAIFENESIN TAB ER 12HR 600 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FUROSEMIDE TAB 40 MG *PEDIATRIC MULTIPLE VITAMIN W/ C SOLN 35 MG/ML** IRBESARTAN TAB 75 MG OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML) Y ACETAMINOPHEN DISINTEGRATING TAB 80 MG *LANCETS*** NORETHINDRONE TAB 0.35 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE) DOCUSATE SODIUM TAB 100 MG SODIUM CHLORIDE AERO SOLN 0.9% DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 30-600 MG SUMATRIPTAN NASAL SPRAY 5 MG/ACT LEVOTHYROXINE SODIUM TAB 125 MCG *MULTIPLE VITAMINS W/ MINERALS CAP**

Appendix F9 15 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG *LANCETS*** DORZOLAMIDE HCL OPHTH SOLN 2% ANTIHEMOPHILIC FACTOR RECOM PEGYLATED-AUCL FOR INJ 500 UNIT Y BEXAROTENE CAP 75 MG Y BISMUTH SUBSALICYLATE SUSP 262 MG/15ML BISACODYL TAB DELAYED RELEASE 5 MG METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV) DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *ADHESIVE BANDAGES - PADS*** *LANCETS*** *VITAMINS A & D CAP*** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** CAPSAICIN CREAM 0.025% SUCCINATE (SLEEP) TAB 25 MG *ADHESIVE BANDAGES*** METFORMIN HCL TAB ER 24HR 750 MG IBUPROFEN CAP 200 MG TRETINOIN GEL 0.025% Y PERMETHRIN AEROSOL 0.5% *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** HCL TAB 25 MG PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV) HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ IRON TAB** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** LINEZOLID FOR SUSP 100 MG/5ML Y *MULTIPLE VITAMINS W/ MINERALS CAP** *VITAMIN MIXTURE CAP**

Appendix F9 16 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACETAMINOPHEN TAB 500 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG *LACTOBACILLUS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *LANCETS*** PYRIDOXINE HCL TAB 50 MG TETRACYCLINE HCL CAP 250 MG ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-1000 MG Y *MULTIPLE VITAMINS W/ MINERALS CAP** DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML LIDOCAINE HCL VISCOUS SOLN 2% POVIDONE-IODINE SOLN 10% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *OMEGA-3 FATTY ACIDS CAP 1000 MG** FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT) LOSARTAN POTASSIUM TAB 100 MG TERBUTALINE SULFATE TAB 5 MG SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF) *LANCETS*** *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** NAPROXEN TAB 500 MG HYPROMELLOSE OPHTH GEL 0.3% *BREWERS YEAST TAB*** LACTULOSE SOLUTION 10 GM/15ML *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** PHENOBARBITAL TAB 15 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 17 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS CAP** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT IBUPROFEN TAB 200 MG *ADHESIVE BANDAGES*** TOBRAMYCIN OPHTH SOLN 0.3% DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML ACETAMINOPHEN CHEW TAB 160 MG *VITAMINS W/ LIPOTROPICS TAB** CEPHALEXIN FOR SUSP 125 MG/5ML LEVOTHYROXINE SODIUM TAB 150 MCG OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG Y TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML) Y HYDROCORTISONE OINT 1% LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE) Y SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) MIDODRINE HCL TAB 10 MG *ADHESIVE BANDAGES*** INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML SODIUM FLUORIDE GEL 1.1% (0.5% F) DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG SENNOSIDES CAP 8.6 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** *LANCETS*** GLYCOPYRROLATE TAB 1 MG *MULTIPLE VITAMINS W/ CALCIUM TAB** *DIAPER RASH PRODUCTS - OINTMENT** PREDNISOLONE ACETATE OPHTH SUSP 1% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG *VAPORIZERS*** BENZOYL PEROXIDE CREAM 10%

Appendix F9 18 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CITRATE-VITAMIN D TAB 200 MG-250 UNIT (ELEMENTAL CA) *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-600 UNIT *LACTOBACILLUS - POWDER** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT ACETAMINOPHEN CHEW TAB 160 MG LOPINAVIR-RITONAVIR TAB 100-25 MG SUPPOS 25 MG GLYCINE DILUENT FOR INJECTION LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) NIZATIDINE CAP 300 MG *MULTIPLE VITAMINS W/ MINERALS TAB** PRAZOSIN HCL CAP 5 MG ACETAMINOPHEN TAB 500 MG CLINDAMYCIN HCL CAP 150 MG MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) Y *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** DISOPYRAMIDE PHOSPHATE CAP ER 12HR 100 MG *MULTIPLE VITAMINS W/ MINERALS CAP** FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** MINOCYCLINE HCL CAP 50 MG RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV) DIPHENHYDRAMINE HCL TAB 25 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** ASPIRIN TAB 500 MG *ADHESIVE BANDAGES*** LAMIVUDINE TAB 300 MG *MULTIPLE VITAMINS W/ CALCIUM TAB** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML

Appendix F9 19 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS PACK** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML HYDROCORTISONE ACETATE CREAM 1% *LANCETS*** DICLOFENAC SODIUM OPHTH SOLN 0.1% ACETAMINOPHEN DISINTEGRATING TAB 80 MG CHLOROQUINE PHOSPHATE TAB 250 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) Y ASPIRIN CHEW TAB 81 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 1177 MG (471 MG CA) OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML ATAZANAVIR SULFATE ORAL POWDER PACKET 50 MG (BASE EQUIV) MECLIZINE HCL TAB 25 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT CARBOXYMETHYLCELL-GLYCERIN-POLYSORB 80 OPHTH SOLN 0.5-1-0.5% CHLORHEXIDINE GLUCONATE PADS 2% DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG INHALATION SUSP 0.5 MG/2ML LISINOPRIL TAB 10 MG *ADHESIVE BANDAGES*** PERMETHRIN CREME RINSE 1% ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TAB 300-150-300 MG HYDROCORTISONE OINT 1% NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG DEXAMETHASONE SOLN 0.5 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML BISACODYL TAB DELAYED RELEASE 5 MG

Appendix F9 20 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MESALAMINE CAP ER 250 MG Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") DARUNAVIR-COBICISTAT TAB 800-150 MG *MULTIPLE VITAMINS W/ MINERALS CAP** DARUNAVIR ETHANOLATE TAB 600 MG (BASE EQUIV) NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR POTASSIUM BICARBONATE EFFER TAB 25 MEQ *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT) Y MELATONIN SUBLINGUAL LOZENGE 5 MG SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML *MULTIPLE VITAMIN TAB** ASPIRIN CHEW TAB 81 MG DELAYED RELEASE TAB 20 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** SULFACETAMIDE SODIUM LOTION 10% (ACNE) *ADHESIVE BANDAGES*** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *LANCETS*** LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG *ADHESIVE BANDAGES*** TAB 200 MG BENZOYL PEROXIDE CREAM 10% METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV) CHOLESTYRAMINE POWDER PACKETS 4 GM GLUCAGON HCL (RDNA) FOR INJ 1 MG (BASE EQUIV) DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML NELFINAVIR MESYLATE TAB 250 MG *ADHESIVE BANDAGES***

Appendix F9 21 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ADHESIVE BANDAGES*** CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG HYDROCORTISONE ENEMA 100 MG/60ML *ADHESIVE BANDAGES*** AMBRISENTAN TAB 10 MG Y HALOBETASOL PROPIONATE OINT 0.05% CAP 200 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *OMEGA-3 FATTY ACIDS CHEW TAB 113.5 MG** *ALCOHOL SWABS*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** LANREOTIDE ACETATE EXTENDED RELEASE INJ 120 MG/0.5ML Y ESTRADIOL VAGINAL TAB 10 MCG *LANCETS*** DOCUSATE CALCIUM CAP 240 MG CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE) CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV) NORETHINDRONE TAB 0.35 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *BREWERS YEAST TAB*** *ALCOHOL SWABS*** PREDNISONE TAB 10 MG DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG SALINE NASAL SPRAY 0.65% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML HYDROCORTISONE LOTION 1% CHLORPHENIRAMINE MALEATE TAB 4 MG

Appendix F9 22 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *SPECIALITY VITAMIN PRODUCT TAB** PREDNISOLONE ACETATE OPHTH SUSP 1% *ACETIC ACID VAGINAL SOLUTION** ALOGLIPTIN-PIOGLITAZONE TAB 25-15 MG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG ASPIRIN TAB DELAYED RELEASE 81 MG POTASSIUM CHLORIDE CAP ER 8 MEQ CARVEDILOL TAB 12.5 MG SENNOSIDES TAB 8.6 MG PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML ASPIRIN TAB 325 MG ACETAMINOPHEN TAB 500 MG *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG CEFPROZIL TAB 250 MG *LANCETS*** *OMEGA-3 FATTY ACIDS CAP 1000 MG** *MULTIPLE VITAMINS W/ MINERALS PACK** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** HYOSCYAMINE SULFATE SL TAB 0.125 MG *BIOFLAVONOID PRODUCTS TAB** NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR *MULTIPLE VITAMINS W/ MINERALS TAB** NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML) Y VALACYCLOVIR HCL TAB 1 GM *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") *VITAMINS A & D CAP***

Appendix F9 23 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG POTASSIUM CHLORIDE TAB ER 10 MEQ CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG *MULTIPLE URINE TEST STRIPS*** FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CHLORPHENIRAMINE MALEATE TAB 4 MG SALINE NASAL SPRAY 0.65% MIDOSTAURIN CAP 25 MG Y FAMOTIDINE TAB 40 MG *MASKS*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT ASPIRIN CHEW TAB 81 MG ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML Y LEVOBUNOLOL HCL OPHTH SOLN 0.5% *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** TAB 100 MG SENNOSIDES TAB 8.6 MG CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) *BIOFLAVONOID PRODUCTS TAB** DIPHENHYDRAMINE HCL CAP 25 MG ACETAMINOPHEN SUPPOS 120 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV) Y GUAIFENESIN LIQUID 100 MG/5ML POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *MULTIPLE VITAMINS W/ MINERALS LIQUID** INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *ALCOHOL SWABS***

Appendix F9 24 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NEOMYCIN SULFATE TAB 500 MG ACETAMINOPHEN TAB ER 650 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** *LANCETS*** *ADHESIVE BANDAGES*** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** DOCUSATE SODIUM CAP 100 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *ADHESIVE BANDAGES*** MORPHINE SULFATE TAB 30 MG Y *ADHESIVE BANDAGES*** BISMUTH SUBSALICYLATE SUSP 262 MG/15ML *ADHESIVE BANDAGES*** *MULTIPLE VITAMIN TAB** INSULIN LISPRO PROT & LISPRO INJ 100 UNIT/ML (75-25) DOCUSATE CALCIUM CAP 240 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000) PROPYLENE GLYCOL-GLYCERIN OPHTH SOLN 1-0.3% CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML LEVOTHYROXINE SODIUM TAB 200 MCG PROMETHAZINE HCL SYRUP 6.25 MG/5ML *LANCETS*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML ASPIRIN CHEW TAB 81 MG BISACODYL SUPPOS 10 MG *ORAL ELECTROLYTE SOLUTION*** FERROUS SULFATE TAB ER 142 MG (45 MG FE EQUIVALENT)

Appendix F9 25 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG DANTROLENE SODIUM CAP 100 MG ACETAMINOPHEN TAB ER 650 MG *MULTIPLE VITAMINS W/ MINERALS TAB** SODIUM CHLORIDE SOLN NEBU 7% CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ALUMINUM & MAGNESIUM HYDROXIDES SUSP 200-200 MG/5ML ONDANSETRON HCL TAB 4 MG ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG ASPIRIN TAB DELAYED RELEASE 81 MG GUAIFENESIN TAB ER 12HR 1200 MG MORPHINE SULFATE TAB ER 200 MG Y PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML FEXOFENADINE HCL TAB 60 MG SELEXIPAG TAB 400 MCG Y TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS LIQUID** *LANCETS*** METOPROLOL TARTRATE TAB 50 MG ALENDRONATE SODIUM TAB 70 MG SENNOSIDES TAB 8.6 MG NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG SEMAGLUTIDE SOLN PEN-INJ 1 MG/DOSE (2 MG/1.5ML) Y FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) *DIAPER RASH PRODUCTS - CREAM** CARBIDOPA & LEVODOPA TAB 10-100 MG DEXAMETHASONE TAB 4 MG NITROGLYCERIN CAP ER 9 MG CONDOMS LATEX LUBRICATED LEVOTHYROXINE SODIUM TAB 137 MCG *MULTIPLE VITAMIN CAP**

Appendix F9 26 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CABOZANTINIB S-MALATE TAB 40 MG (BASE EQUIVALENT) Y LEVOTHYROXINE SODIUM TAB 50 MCG EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TAB 200-25 MG *LANCETS*** *VITAMINS C & E CAP*** DILTIAZEM HCL CAP ER 24HR 180 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG NAPROXEN SODIUM TAB 220 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ IRON TAB** BUDESONIDE NASAL SUSP 32 MCG/ACT VERAPAMIL HCL CAP ER 24HR 200 MG POVIDONE-IODINE SOLN 10% BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT) CONDOMS LATEX LUBRICATED *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CLOTRIMAZOLE VAGINAL CREAM 1% *MULTIPLE VITAMIN CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** ERGOTAMINE W/ CAFFEINE TAB 1-100 MG *MULTIPLE VITAMINS W/ MINERALS CAP** NADOLOL TAB 20 MG FENOFIBRATE TAB 145 MG DEXTRAN 70-HYPROMELLOSE OPHTH SOLN 0.1-0.3% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-300 MG/5ML COBICISTAT TAB 150 MG SELENIUM SULFIDE LOTION 1% *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *ALCOHOL SWABS*** PROMETHAZINE-DM SYRUP 6.25-15 MG/5ML

Appendix F9 27 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CYCLOSPORINE MODIFIED CAP 50 MG BENZOYL PEROXIDE LIQ 5% *B-COMPLEX VITAMIN TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT Y *MULTIPLE VITAMINS W/ MINERALS TAB** DOCUSATE SODIUM TAB 100 MG MICONAZOLE NITRATE OINTMENT 2% DIPHENHYDRAMINE HCL TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** GUAIFENESIN TAB ER 12HR 1200 MG DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG CHOLESTYRAMINE POWDER 4 GM/DOSE ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML CARBOXYMETHYLCELLULOSE-HYPROMELLOSE GEL 0.25-0.3% INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30) MICONAZOLE NITRATE OINTMENT 2% OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML Y ASPIRIN TAB 325 MG *SPECIALITY VITAMIN PRODUCT TAB ER** AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG CALCIUM CARBONATE-ERGOCALCIFEROL TAB 250 MG-125 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** LACTIC ACID (AMMONIUM LACTATE) LOTION 12% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML STAVUDINE CAP 20 MG *ARTIFICIAL TEAR OPHTH OINTMENT*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT BETAMETHASONE DIPROPIONATE CREAM 0.05% *ADHESIVE BANDAGES - PADS*** ASPIRIN TAB DELAYED RELEASE 325 MG *ADHESIVE BANDAGES*** TERBUTALINE SULFATE TAB 2.5 MG

Appendix F9 28 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *CALAMINE LOTION*** PEGFILGRASTIM-CBQV SOLN PREFILLED SYRINGE 6 MG/0.6ML Y CARBOXYMETHYLCELLULOSE-GLYCERIN OPHTH SOLN 0.5-0.9% GUAIFENESIN LIQUID 100 MG/5ML IBUPROFEN TAB 200 MG LEVOTHYROXINE SODIUM TAB 112 MCG THIAMINE HCL TAB 100 MG ERGOCALCIFEROL CAP 50 MCG (2000 UNIT) GLIPIZIDE TAB ER 24HR 2.5 MG AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML MECLIZINE HCL TAB 25 MG RIVAROXABAN TAB 10 MG CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-100 UNIT-40 MCG *RESPIRATORY THERAPY SUPPLIES - MISC** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** IBUPROFEN SUSP 100 MG/5ML *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG *MULTIPLE VITAMINS W/ IRON TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** *B-COMPLEX W/ C & FOLIC ACID TAB ER*** *ORAL ELECTROLYTE SOLUTION*** OYSTER SHELL CALCIUM TAB 500 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB ER** OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG PYRIDOXINE HCL TAB 25 MG HYOSCYAMINE SULFATE SL TAB 0.125 MG NAPROXEN SODIUM CAP 220 MG CALCIUM W/ MAGNESIUM TAB 250-125 MG LOPERAMIDE HCL TAB 2 MG

Appendix F9 29 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS LIQUID** DOCUSATE SODIUM CAP 250 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** HYDROCORTISONE GEL 1% *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG CLOTRIMAZOLE CREAM 1% *MULTIPLE URINE TEST STRIPS*** LAMIVUDINE ORAL SOLN 10 MG/ML *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS PACK** FLUOCINONIDE GEL 0.05% *MULTIPLE VITAMINS W/ MINERALS TAB** *BIOFLAVONOID PRODUCTS TAB ER** IRBESARTAN TAB 150 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** METHOTREXATE SOLN PF AUTO-INJECTOR 25 MG/0.5ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG *LANCETS*** STAVUDINE CAP 40 MG CHLORPHENIRAMINE MALEATE TAB 4 MG RUXOLITINIB PHOSPHATE TAB 25 MG (BASE EQUIVALENT) Y ASPIRIN CHEW TAB 81 MG GLUCAGON (RDNA) FOR INJ KIT 1 MG CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** LIDOCAINE PATCH 4%

Appendix F9 30 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT) ACETAMINOPHEN CHEW TAB 80 MG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) *LACTOBACILLUS CHEW TAB** SENNOSIDES TAB 8.6 MG ETONOGESTREL SUBDERMAL IMPLANT 68 MG DIGOXIN TAB 250 MCG (0.25 MG) PROPYLTHIOURACIL TAB 50 MG *MULTIPLE VITAMIN TAB** INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ML (70-30) *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT ANAGRELIDE HCL CAP 1 MG HYDROCORTISONE CREAM 1% DISOPYRAMIDE PHOSPHATE CAP ER 12HR 150 MG *RESPIRATORY THERAPY SUPPLIES - MISC** OLODATEROL HCL INHAL AEROSOL SOLN 2.5 MCG/ACT (BASE EQUIV) METRONIDAZOLE GEL 0.75% *ADHESIVE BANDAGES*** HYDROCORTISONE-ALOE VERA CREAM 1% TRIAMCINOLONE ACETONIDE LOTION 0.1% *MULTIPLE VITAMINS W/ MINERALS CAP** HCL OPHTH SOLN 0.05% PEGINTERFERON ALFA-2A INJ 180 MCG/ML Y CHLORHEXIDINE GLUCONATE SOLN 4% CLONIDINE HCL TAB 0.2 MG IBUPROFEN TAB 100 MG *MULTIPLE VITAMIN CAP** ACETAMINOPHEN LIQUID 167 MG/5ML OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML) Y

Appendix F9 31 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs SOTALOL HCL TAB 80 MG ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR *ORAL ELECTROLYTE SOLUTION*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** INDINAVIR SULFATE CAP 400 MG ACETAMINOPHEN W/ CODEINE TAB 300-30 MG Y SALINE NASAL SPRAY 0.65% CALCIUM-CHOLECALCIFEROL TAB 500 MG-200 UNIT *LANCETS*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *SPECIALITY VITAMIN PRODUCT TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 1177 MG (471 MG CA) NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG *MASKS*** OMEPRAZOLE MAGNESIUM CAP DR 20.6 MG (20 MG BASE EQUIV) *LANCETS*** *MULTIPLE VITAMIN TAB** INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *ALCOHOL SWABS*** *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** BECLOMETHASONE DIPROP HFA BREATH ACT INH AER 80 MCG/ACT HYDROCORTISONE CREAM 0.5% CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) CIMETIDINE HCL SOLN 300 MG/5ML CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) VISMODEGIB CAP 150 MG Y CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT *LANCETS*** *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG***

Appendix F9 32 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** FUMARATE TAB 2.68 MG *MULTIPLE VITAMINS W/ MINERALS CAP** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS CAP** CHLORHEXIDINE GLUCONATE LIQUID 4% *LACTOBACILLUS CAP** CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT IVACAFTOR TAB 150 MG Y CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT *MULTIPLE VITAMINS W/ MINERALS CAP** LISINOPRIL TAB 30 MG *LANCETS*** *RESPIRATORY THERAPY SUPPLIES - MISC** BENZOYL PEROXIDE GEL 2.5% MINOCYCLINE HCL CAP 75 MG *RESPIRATORY THERAPY SUPPLIES - MISC** *RESPIRATORY THERAPY SUPPLIES - MISC** *B-COMPLEX W/ C & FOLIC ACID TAB*** *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG*** SODIUM EXTENDED CAP 30 MG ASPIRIN TAB DELAYED RELEASE 81 MG LEVOCARNITINE (DIETARY) ORAL SOLN 1 GM/10ML *OMEGA-3 FATTY ACIDS CAP 1400 MG** GUAIFENESIN LIQUID 100 MG/5ML ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 5 MG (BASE EQUIV) Y *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** HYDROCORTISONE CREAM 1%

Appendix F9 33 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MIDODRINE HCL TAB 5 MG SALINE NASAL SPRAY 0.65% *ADHESIVE BANDAGES*** GUAIFENESIN SYRUP 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** EPOETIN ALFA-EPBX INJ 40000 UNIT/ML Y HYDROXYUREA CAP 500 MG *MULTIPLE VITAMINS W/ MINERALS TAB** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG RAMIPRIL CAP 5 MG ACETAMINOPHEN CAP 500 MG URSODIOL TAB 250 MG *MULTIPLE VITAMIN TAB** INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) Y CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG CALCIUM CITRATE-VITAMIN D TAB 250 MG-200 UNIT (ELEMENTAL CA) LEVOTHYROXINE SODIUM TAB 175 MCG CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG *SPECIALITY VITAMIN PRODUCT TAB** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG *MULTIPLE VITAMINS W/ MINERALS CAP** IPRATROPIUM-ALBUTEROL INHAL AEROSOL SOLN 20-100 MCG/ACT IVABRADINE HCL TAB 7.5 MG (BASE EQUIV) *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML*** DONEPEZIL HYDROCHLORIDE TAB 23 MG SOMATROPIN INJ 15 MG/1.5ML Y DOCUSATE CALCIUM CAP 240 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG LORATADINE SYRUP 5 MG/5ML *LANCETS***

Appendix F9 34 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ASPIRIN TAB DELAYED RELEASE 325 MG *SPECIALITY VITAMIN PRODUCT TAB** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") MELATONIN TAB 1 MG *MULTIPLE VITAMIN TAB** KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) *MULTIPLE VITAMIN TAB** HYDROCORTISONE CREAM 1% LUSUTROMBOPAG TAB 3 MG Y CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT) LEVONORGESTREL TAB 1.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FOLIC ACID TAB 1 MG SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) GUAIFENESIN LIQUID 100 MG/5ML *MULTIPLE VITAMIN TAB** *LACTOBACILLUS CAP** GUAIFENESIN LIQUID 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES TAB 15 MG PROPYLENE GLYCOL-GLYCERIN OPHTH SOLN 1-0.3% DOCUSATE SODIUM LIQUID 50 MG/15ML CICLOPIROX SHAMPOO 1% CARBAMIDE PEROXIDE 6.5% OTIC SOLN *MULTIPLE VITAMINS W/ MINERALS TAB** CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) *MULTIPLE VITAMINS W/ IRON TAB** CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) GLIPIZIDE TAB 10 MG *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *OMEGA-3 FATTY ACIDS CAP 1000 MG** *ADHESIVE BANDAGES***

Appendix F9 35 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG *VITAMIN C-VITAMIN D-ZINC TAB*** BENZOYL PEROXIDE CREAM 10% *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** SIMETHICONE LIQUID 40 MG/0.6ML APREPITANT CAPSULE 80 MG Y BISACODYL TAB DELAYED RELEASE 5 MG HYDROCORTISONE OINT 0.5% *B-COMPLEX W/BIOTIN & FOLIC ACID CAP ER*** TRETINOIN GEL 0.025% Y INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *ADHESIVE BANDAGES*** ONDANSETRON HCL ORAL SOLN 4 MG/5ML INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG BUTALBITAL-ASPIRIN-CAFFEINE TAB 50-325-40 MG IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY) INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") LEVOTHYROXINE SODIUM TAB 300 MCG FERROUS SULFATE DRIED TAB ER 45 MG (FE EQUIVALENT) GUAIFENESIN LIQUID 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** EFAVIRENZ TAB 600 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** SIMETHICONE CHEW TAB 80 MG *B-COMPLEX W/ C TAB** MELATONIN TABLET DISINTEGRATING 10 MG *MULTIPLE VITAMIN TAB** SIMETHICONE CHEW TAB 80 MG

Appendix F9 36 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** *LANCETS*** CALCIUM CITRATE-VITAMIN D TAB 200 MG-250 UNIT (ELEMENTAL CA) NEOMYCIN-POLYMY-GRAMICID OP SOL 1.75-10000-0.025MG-UNT-MG/ML TRAMADOL HCL TAB ER 24HR 100 MG Y *LANCETS*** *B-COMPLEX W/ C & FOLIC ACID TAB*** PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM *B-COMPLEX W/BIOTIN & FOLIC ACID CAP*** TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG *VITAMIN A-VITAMIN D-MINERALS CAP*** SENNOSIDES SYRUP 8.8 MG/5ML CHLORPHENIRAMINE MALEATE TAB 4 MG *MULTIPLE VITAMINS W/ MINERALS TAB** SODIUM FLUORIDE CREAM 1.1% *MULTIPLE VITAMINS W/ MINERALS TAB** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 60 MCG/0.3ML Y DIPHENHYDRAMINE HCL TAB 25 MG *ADHESIVE BANDAGES*** FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE) *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT *B-COMPLEX W/ LYSINE-MIN-FE & FA LIQD 800-15-1 MG/15ML*** *B-COMPLEX W/ C & E + ZN TAB*** FENTANYL TD PATCH 72HR 50 MCG/HR Y *RESPIRATORY THERAPY SUPPLIES - MISC** SODIUM FLUORIDE GEL 1.1% (0.5% F) *LANCETS*** DIPHENHYDRAMINE HCL TAB 25 MG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG

Appendix F9 37 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT CLOTRIMAZOLE VAGINAL CREAM 2% ENOXAPARIN SODIUM INJ 60 MG/0.6ML *LANCETS*** *SPECIALITY VITAMIN PRODUCT CAP** AXITINIB TAB 1 MG Y HYDROCORTISONE CREAM 1% DIPYRIDAMOLE TAB 75 MG MELATONIN TABLET DISINTEGRATING 3 MG DESOXIMETASONE CREAM 0.05% *LACTOBACILLUS RHAMNOSUS (GG) PACKET** WARFARIN SODIUM TAB 10 MG LEVONORGESTREL TAB 1.5 MG LOMUSTINE CAP 100 MG LEVONORGESTREL TAB 1.5 MG GUAIFENESIN LIQUID 100 MG/5ML CEFTRIAXONE SODIUM FOR INJ 2 GM ACETAMINOPHEN TAB ER 650 MG BACLOFEN TAB 20 MG IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG CAPSAICIN LOTION 0.035% NAPROXEN SODIUM TAB 220 MG DOCUSATE SODIUM CAP 100 MG ALCLOMETASONE DIPROPIONATE OINT 0.05% CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG *LANCETS*** *DIAPER RASH PRODUCTS - OINTMENT** CHLOROQUINE PHOSPHATE TAB 500 MG NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG ACETAMINOPHEN TAB ER 650 MG *LACTOBACILLUS CAP**

Appendix F9 38 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NINTEDANIB ESYLATE CAP 100 MG (BASE EQUIVALENT) Y *B-COMPLEX W/ IRON & MINERALS ELIXIR** ASPIRIN TAB 325 MG *LACTOBACILLUS RHAMNOSUS (GG) CAP** DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG MEMANTINE HCL TAB 10 MG CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) Y *DIAPER RASH PRODUCTS - OINTMENT** *MULTIPLE VITAMINS W/ MINERALS TAB** BISMUTH SUBSALICYLATE CHEW TAB 262 MG CEPHALEXIN CAP 500 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** LOPERAMIDE HCL CAP 2 MG CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 X 20 MG (140 DOSE) KIT Y CEFDINIR CAP 300 MG *LACTOBACILLUS RHAMNOSUS (GG) CHEW TAB** *LANCETS*** SODIUM EC TAB 40 MG (BASE EQUIV) *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** GUAIFENESIN TAB ER 12HR 1200 MG *PEDIATRIC MULTIPLE VITAMIN CHEW TAB** CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *MULTIPLE VITAMINS W/ MINERALS CAP** CHOLECALCIFEROL TAB 125 MCG (5000 UNIT) HYDROCORTISONE OINT 1% *LACTOBACILLUS RHAMNOSUS (GG) CAP** INTERFERON BETA-1A PREF SYR 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML Y *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** CALCIUM CITRATE-VITAMIN D TAB 200 MG-250 UNIT (ELEMENTAL CA)

Appendix F9 39 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs BENZOYL PEROXIDE GEL 10% MICONAZOLE NITRATE POWDER 2% *LANCETS*** LEVOFLOXACIN ORAL SOLN 25 MG/ML METRONIDAZOLE LOTION 0.75% *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *OMEGA-3 FATTY ACIDS CAP 1000 MG** *LACTOBACILLUS RHAMNOSUS (GG) PACKET** DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** PROPRANOLOL HCL TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG CLONIDINE HCL TAB 0.3 MG MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT *MULTIPLE VITAMINS W/ MINERALS CAP** *RESPIRATORY THERAPY SUPPLIES - MISC** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML IM INJ IN OIL 200 MG/ML Y ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV) Y RIFAXIMIN TAB 550 MG Y *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *B-COMPLEX W/ C & FOLIC ACID TAB*** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** *MULTIPLE VITAMINS W/ MINERALS TAB** SELEXIPAG TAB 1600 MCG Y AMANTADINE HCL CAP 100 MG SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT) Y ACETAMINOPHEN LIQUID 167 MG/5ML

Appendix F9 40 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MICONAZOLE NITRATE VAGINAL SUPPOS 100 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) *IRON W/ VITAMIN LIQ** *ADHESIVE BANDAGES*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN OXYCODONE HCL TAB 20 MG Y *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG MYCOPHENOLATE MOFETIL CAP 250 MG LEVOTHYROXINE SODIUM TAB 100 MCG *LANCETS*** PINDOLOL TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG *MASKS*** CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) DICYCLOMINE HCL TAB 20 MG HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML DIGOXIN TAB 250 MCG (0.25 MG) CLOTRIMAZOLE VAGINAL CREAM 2% LORATADINE SYRUP 5 MG/5ML *ADHESIVE BANDAGES*** *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML*** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** CETIRIZINE HCL TAB 10 MG TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML Y CETIRIZINE HCL CHEW TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 41 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG *ADHESIVE BANDAGES*** PROMETHAZINE & PHENYLEPHRINE SYRUP 6.25-5 MG/5ML *LANCETS*** DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) CEPHALEXIN TAB 250 MG DANTROLENE SODIUM CAP 50 MG CASTOR OIL NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML Y *ADHESIVE BANDAGES*** CORTICOTROPIN INJ GEL 80 UNIT/ML Y *ADHESIVE BANDAGES - PADS*** BENZOYL PEROXIDE GEL 10% ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML *RESPIRATORY THERAPY SUPPLIES - MISC** METHOTREXATE SOLN PF AUTO-INJECTOR 7.5 MG/0.15ML Y *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** METOPROLOL TARTRATE TAB 25 MG DIGOXIN TAB 250 MCG (0.25 MG) *ADHESIVE BANDAGES*** BRIMONIDINE TARTRATE OPHTH SOLN 0.15% GENTAMICIN SULFATE OPHTH SOLN 0.3% SENNOSIDES SYRUP 8.8 MG/5ML STAVUDINE CAP 30 MG BISACODYL TAB DELAYED RELEASE 5 MG PSEUDOEPHEDRINE HCL TAB 30 MG *LANCETS*** FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG ASPIRIN TAB 325 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT) Y

Appendix F9 42 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ERYTHROMYCIN SOLN 2% PHENAZOPYRIDINE HCL TAB 200 MG OLIVE OIL BISACODYL SUPPOS 10 MG *MULTIPLE VITAMINS W/ CALCIUM TAB** SENNOSIDES SYRUP 8.8 MG/5ML CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) Y *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** ALOGLIPTIN BENZOATE TAB 25 MG (BASE EQUIV) CAPSAICIN CREAM 0.025% MICONAZOLE NITRATE POWDER 2% *MULTIPLE VITAMINS W/ MINERALS TAB** PILOCARPINE HCL TAB 5 MG CYCLOSPORINE MODIFIED CAP 100 MG DOCUSATE SODIUM CAP 250 MG OLIVE OIL *LANCETS*** *LANCETS*** *LANCETS*** *LACTOBACILLUS REUTERI PACKET** *ANTISEPTIC PRODUCTS MISC - PADS** *ADHESIVE BANDAGES - PADS*** MICONAZOLE NITRATE VAGINAL APP 200 MG & 2% CREAM 9 GM KIT SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG DOCUSATE SODIUM TAB 100 MG NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG METRONIDAZOLE VAGINAL GEL 0.75% *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *ALCOHOL SWABS***

Appendix F9 43 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LACTOBACILLUS REUTERI CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** BISMUTH SUBSALICYLATE SUSP 262 MG/15ML CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG DOCUSATE SODIUM LIQUID 150 MG/15ML MELATONIN TABLET DISINTEGRATING 3 MG *OMEGA-3 FATTY ACIDS CAP 1200 MG** MAGNESIUM TAB DELAYED RELEASE 20 MG FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) TOLNAFTATE CREAM 1% POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *MULTIPLE VITAMINS W/ MINERALS CAP** *LANCETS*** AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML PSEUDOEPHEDRINE HCL TAB 30 MG CALCIUM TAB 600 MG DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG *LACTOBACILLUS REUTERI LIQUID** *ADHESIVE BANDAGES*** FAMOTIDINE TAB 20 MG TAB ER 24HR 120 MG PROPYLENE GLYCOL-GLYCERIN OPHTH SOLN 1-0.3% *MULTIPLE VITAMINS W/ MINERALS CAP** SAQUINAVIR MESYLATE TAB 500 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG HYOSCYAMINE SULFATE TAB DISINT 0.125 MG DEXAMETHASONE TAB 0.5 MG

Appendix F9 44 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs PAZOPANIB HCL TAB 200 MG (BASE EQUIV) Y CALCIUM CARBONATE-VITAMIN D TAB 500 MG-125 UNIT *ADHESIVE BANDAGES*** CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) *ADHESIVE BANDAGES*** LORATADINE CAP 10 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-200 UNIT *LANCETS*** *ALCOHOL SWABS*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) Y SOTALOL HCL TAB 120 MG *B-COMPLEX W/ MINERALS LIQ** CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) CHLORHEXIDINE GLUCONATE DRESSING *MASKS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** HYOSCYAMINE SULFATE SL TAB 0.125 MG CHLORHEXIDINE GLUCONATE DRESSING *PEDIATRIC VITAMIN CHEW TAB** *BIOFLAVONOID PRODUCTS TAB ER** CHLORHEXIDINE GLUCONATE DRESSING *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** BENZOYL PEROXIDE CREAM 10% ERYTHROMYCIN GEL 2% TOLNAFTATE SOLN 1% *MULTIPLE VITAMINS W/ MINERALS TAB ER** CLONIDINE HCL TAB 0.1 MG TORSEMIDE TAB 20 MG HCL SYRUP 2 MG/5ML IRBESARTAN TAB 300 MG CHOLECALCIFEROL CAP 50 MCG (2000 UNIT)

Appendix F9 45 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DOCOSANOL CREAM 10% SIMETHICONE SUSP 40 MG/0.6ML DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN CHEW TAB 81 MG PROGESTERONE MICRONIZED CAP 200 MG OMEPRAZOLE DELAYED RELEASE TAB 20 MG NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** SENNOSIDES CHEW TAB 15 MG *B-COMPLEX W/ C TAB ER** LEVOTHYROXINE SODIUM TAB 100 MCG *ADHESIVE BANDAGES*** METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV) AZATHIOPRINE TAB 75 MG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) NORETHINDRONE TAB 0.35 MG *ADHESIVE BANDAGES*** LIDOCAINE PATCH 4% ITRACONAZOLE CAP 100 MG Y *MULTIPLE VITAMIN TAB** PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4% LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG FLUOROMETHOLONE OPHTH SUSP 0.1% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CAP** TRIAMCINOLONE ACETONIDE OINT 0.025% *MULTIPLE URINE TEST STRIPS*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *LANCETS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)

Appendix F9 46 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES CHEW TAB 15 MG ACETAMINOPHEN TAB ER 650 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG CALCIPOTRIENE OINT 0.005% Y CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT) MELATONIN CHEW TAB 2.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") GUAIFENESIN LIQUID 100 MG/5ML TERCONAZOLE VAGINAL CREAM 0.4% LEVONORGESTREL RELEASING IUD 20 MCG/DAY (52 MG TOTAL) *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** ROMIDEPSIN FOR IV INJ 10 MG Y DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG BISACODYL TAB DELAYED RELEASE 5 MG POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG) GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ IRON CAP ** DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG ACETAMINOPHEN W/ CODEINE TAB 300-15 MG Y POLYVINYL ALCOHOL-POVIDONE OPHTH SOLN 5-6 MG/ML (0.5-0.6%) *ADHESIVE BANDAGES*** MELATONIN SL TAB 5 MG *LANCETS*** CETIRIZINE HCL TAB 10 MG RAMIPRIL CAP 10 MG *MULTIPLE VITAMINS W/ MINERALS PACK** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG KETOROLAC TROMETHAMINE OPHTH SOLN 0.4%

Appendix F9 47 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** *SPECIALITY VITAMIN PRODUCT TAB** *MULTIPLE VITAMINS W/ IRON TAB** OMEPRAZOLE CAP DELAYED RELEASE 20 MG OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML) Y EPOETIN ALFA-EPBX INJ 10000 UNIT/ML Y LOSARTAN POTASSIUM TAB 25 MG NAPROXEN TAB EC 500 MG BISMUTH SUBSALICYLATE SUSP 525 MG/15ML *OMEGA-3 FATTY ACIDS CAP 300 MG** *LANCETS*** LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG *OMEGA-3 FATTY ACIDS CAP 1400 MG** *LANCETS*** *LANCETS*** FEXOFENADINE HCL TAB 180 MG MELATONIN TABLET DISINTEGRATING 5 MG MICONAZOLE NITRATE VAGINAL APP 200 MG & 2% CREAM 9 GM KIT CIMETIDINE TAB 200 MG CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) *LANCETS*** *ALCOHOL SWABS*** MEMANTINE HCL TAB 10 MG ETHOSUXIMIDE SOLN 250 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *BACITRACIN-POLYMYXIN B OINT*** PSEUDOEPHEDRINE W/ DM-GG LIQUID 30-10-100 MG/5ML ELVITEGRAV-COBIC-EMTRICITAB-TENOFOV AF TAB 150-150-200-10 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML*** *MULTIPLE VITAMINS W/ MINERALS CAP** DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG Y CETIRIZINE HCL TAB 10 MG

Appendix F9 48 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LORATADINE SYRUP 5 MG/5ML CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT MELATONIN LIQUID 5 MG/15ML POTASSIUM CHLORIDE CAP ER 10 MEQ MIDODRINE HCL TAB 2.5 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") ALOGLIPTIN-PIOGLITAZONE TAB 25-45 MG *LANCETS*** POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% GLIMEPIRIDE TAB 1 MG AMILORIDE HCL TAB 5 MG BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 160-4.5 MCG/ACT Y MICONAZOLE NITRATE CREAM 2% ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ) FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** IM SOLN 100 MG/ML Y NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG MICONAZOLE NITRATE CREAM 2% FENOFIBRATE MICRONIZED CAP 134 MG *LANCETS*** NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG *B-COMPLEX W/ MINERALS LIQ** ASPIRIN TAB 325 MG CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT ASPIRIN TAB DELAYED RELEASE 81 MG OXYCODONE HCL SOLN 5 MG/5ML Y PYRIDOXINE HCL TAB 50 MG *CONDOMS - MALE*** *MULTIPLE VITAMINS W/ IRON TAB** *SPECIALITY VITAMIN PRODUCT TAB ER** SENNOSIDES TAB 8.6 MG

Appendix F9 49 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** LEVOTHYROXINE SODIUM TAB 25 MCG *MULTIPLE VITAMINS W/ MINERALS PACK** *SPECIALITY VITAMIN PRODUCT TAB** *B-COMPLEX W/ C & E + ZN TAB*** FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT DORZOLAMIDE HCL OPHTH SOLN 2% *LANCETS*** NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) Y *LANCETS*** ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT) Y CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** BISMUTH SUBSALICYLATE TAB 262 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *SPECIALITY VITAMIN PRODUCT TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** DEXAMETHASONE TAB 0.5 MG *LANCETS*** TRAMADOL HCL TAB ER 24HR 200 MG Y *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** LOPINAVIR-RITONAVIR TAB 200-50 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** METRONIDAZOLE TAB 500 MG LACTIC ACID (AMMONIUM LACTATE) LOTION 12% LIDOCAINE PATCH 4% DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG CALCIUM CARBONATE (ANTACID) TAB 648 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML LEVOCARNITINE (DIETARY) ORAL SOLN 1 GM/10ML

Appendix F9 50 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ IRON TAB** MICONAZOLE NITRATE VAG APP 100 MG & 2% CREAM 9 GM KIT ACETAMINOPHEN CHEW TAB 80 MG EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 133-200 MG *COPPER IUD** *MULTIPLE VITAMINS W/ MINERALS TAB** SALINE NASAL SPRAY 0.65% *B-COMPLEX VITAMIN TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG *B-COMPLEX VITAMIN TAB** ZIDOVUDINE SYRUP 10 MG/ML LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) Y SIMETHICONE CHEW TAB 125 MG HYOSCYAMINE SULFATE SL TAB 0.125 MG ACETAMINOPHEN LIQUID 167 MG/5ML *ADHESIVE BANDAGES*** SODIUM CHLORIDE AERO SOLN 0.9% SIMETHICONE CHEW TAB 125 MG GUAIFENESIN TAB ER 12HR 1200 MG *LANCETS*** FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 24HR 180-240 MG BISACODYL TAB DELAYED RELEASE 5 MG MELOXICAM TAB 15 MG *RESPIRATORY THERAPY SUPPLIES - MISC** TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG BISACODYL TAB DELAYED RELEASE 5 MG *LANCETS*** DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG DIPHENHYDRAMINE HCL CAP 50 MG AMOXICILLIN & K CLAVULANATE TAB 875-125 MG SENNOSIDES LIQUID 25 MG/15ML

Appendix F9 51 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VITAMINS W/ LIPOTROPICS CAP** FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *MULTIPLE VITAMINS W/ IRON TAB** *ADHESIVE BANDAGES - PADS*** ASPIRIN TAB 325 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) TRETINOIN CAP 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *BIOFLAVONOID PRODUCTS CAP** APREPITANT CAPSULE 125 MG Y *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** SODIUM FLUORIDE CREAM 1.1% ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.14 MG/DAY ASPIRIN TAB DELAYED RELEASE 325 MG *RESPIRATORY THERAPY SUPPLIES - MISC** FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) *LANCETS*** EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB 200-25-300 MG EPLERENONE TAB 50 MG *LANCETS*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *B-COMPLEX W/ C TAB** *CONDOMS - MALE*** LEVONORGESTREL RELEASING IUD 17.5 MCG/DAY (19.5 MG TOTAL) ASPIRIN TAB DELAYED RELEASE 325 MG BENZOYL PEROXIDE LIQ 10% LOMUSTINE CAP 40 MG ASPIRIN TAB DELAYED RELEASE 325 MG *MULTIPLE URINE TEST STRIPS*** CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)

Appendix F9 52 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TEMOZOLOMIDE CAP 180 MG Y CEFTRIAXONE SODIUM FOR INJ 1 GM *B-COMPLEX W/ C CAP** SELEXIPAG TAB 200 MCG Y FAMOTIDINE TAB 20 MG BISACODYL TAB DELAYED RELEASE 5 MG *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *ADHESIVE BANDAGES*** ACETAMINOPHEN LIQUID 160 MG/5ML BACLOFEN TAB 10 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *OMEGA-3 FATTY ACIDS CAP 500 MG** NITROGLYCERIN CAP ER 2.5 MG CLOTRIMAZOLE SOLN 1% *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT) Y LEVOTHYROXINE SODIUM TAB 112 MCG *LACTOBACILLUS CAP** MICONAZOLE NITRATE VAGINAL SUPP 1200 MG & 2% CREAM KIT TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML) Y *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** PROPAFENONE HCL CAP ER 12HR 325 MG *ADHESIVE BANDAGES - PADS*** CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ *BIOFLAVONOID PRODUCTS CHEW TAB** *LANCETS*** ACETAMINOPHEN LIQUID 160 MG/5ML CYCLOSPORINE CAP 25 MG CEFPROZIL FOR SUSP 125 MG/5ML CAPSAICIN CREAM 0.1%

Appendix F9 53 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-500 UNIT *LANCETS*** *LANCETS*** PINDOLOL TAB 5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES - PADS*** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% DICYCLOMINE HCL CAP 10 MG AMOXICILLIN (TRIHYDRATE) CAP 250 MG SACUBITRIL-VALSARTAN TAB 97-103 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) *ADHESIVE BANDAGES*** CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-500 UNIT LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** *LANCETS*** HYDROCORTISONE CREAM 1% *ALCOHOL SWABS*** CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) *ADHESIVE BANDAGES***

Appendix F9 54 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV) SELEXIPAG TAB THERAPY PACK 200 MCG (140) & 800 MCG (60) Y TORSEMIDE TAB 100 MG POTASSIUM CHLORIDE TAB ER 10 MEQ ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR) *BACTERIOSTATIC SODIUM CHLORIDE INJ SOLN 0.9%*** DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG *LANCETS*** *LANCETS*** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL TAB 50-25 MG (BASE EQ) PSEUDOEPHEDRINE W/ COD-GG SYRUP 30-10-100 MG/5ML *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG *ADHESIVE BANDAGES*** SENNOSIDES TAB 8.6 MG BENZOYL PEROXIDE LIQ 10% WATER FOR INJECTION *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *ADHESIVE BANDAGES*** TENOFOVIR DISOPROXIL FUMARATE TAB 250 MG *LANCETS*** *LANCETS*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** METFORMIN HCL TAB ER 24HR 500 MG ASPIRIN TAB DELAYED RELEASE 325 MG GUAIFENESIN TAB 200 MG ACETAMINOPHEN LIQUID 160 MG/5ML LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG NEVIRAPINE TAB ER 24HR 400 MG GENTAMICIN SULFATE OPHTH OINT 0.3% FENTANYL TD PATCH 72HR 25 MCG/HR Y

Appendix F9 55 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DIGOXIN TAB 125 MCG (0.125 MG) FEXOFENADINE HCL SUSP 30 MG/5ML (6 MG/ML) PRAVASTATIN SODIUM TAB 80 MG *LANCETS*** FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE) INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** *LANCETS*** *MULTIPLE VITAMIN CHEW TAB** HYOSCYAMINE SULFATE TAB DISINT 0.125 MG CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) *MULTIPLE VITAMINS W/ MINERALS CAP** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML** FLUOCINOLONE ACETONIDE OINT 0.025% IBUPROFEN TAB 200 MG ANTIHEMOPHILIC FACTOR RECOM PEGYLATED-AUCL FOR INJ 1000 UNIT Y ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG *RESPIRATORY THERAPY SUPPLIES - MISC** MELATONIN TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FELODIPINE TAB ER 24HR 2.5 MG *ADHESIVE BANDAGES - PADS*** *ADHESIVE BANDAGES - PADS*** *MULTIPLE VITAMINS W/ MINERALS PACK** ASPIRIN SUPPOS 600 MG CLOTRIMAZOLE CREAM 1% *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML CALCIUM W/ MAGNESIUM TAB 333-167 MG *ADHESIVE BANDAGES - PADS*** LEVOTHYROXINE SODIUM TAB 125 MCG

Appendix F9 56 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MASKS*** ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML) *RESPIRATORY THERAPY SUPPLIES - MISC** *MULTIPLE VITAMINS W/ MINERALS TAB** SIMETHICONE CAP 180 MG *ADHESIVE BANDAGES*** CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-15 MG HYDROCORTISONE-ALOE VERA CREAM 1% *MULTIPLE VITAMINS W/ MINERALS PACK** *OMEGA-3 FATTY ACIDS CAP 1000 MG** NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG EVEROLIMUS TAB 7.5 MG Y CEFDINIR FOR SUSP 250 MG/5ML BENZOYL PEROXIDE LIQ 4% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML SENNOSIDES TAB 8.6 MG FELODIPINE TAB ER 24HR 5 MG CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) *LANCETS*** ACETAMINOPHEN SUSP 160 MG/5ML *LANCETS*** NIZATIDINE ORAL SOLN 15 MG/ML HYDROMORPHONE HCL TAB 2 MG Y SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML *MULTIPLE VITAMINS W/ MINERALS LIQUID** EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 600-300-300 MG ENOXAPARIN SODIUM INJ 80 MG/0.8ML METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21) DOCUSATE SODIUM CAP 250 MG *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** *ADHESIVE BANDAGES*** DULAGLUTIDE SOLN PEN-INJECTOR 1.5 MG/0.5ML Y LACTIC ACID (AMMONIUM LACTATE) LOTION 12%

Appendix F9 57 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs POVIDONE-IODINE OINT 10% IBUPROFEN SUSP 40 MG/ML *ADHESIVE BANDAGES*** *BIOFLAVONOID PRODUCTS CAP** CARBOXYMETHYLCELLULOSE-GLYCERIN OPHTH SOLN 0.5-0.9% DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML ALOGLIPTIN BENZOATE TAB 12.5 MG (BASE EQUIV) RIFAMPIN CAP 150 MG *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** FAMOTIDINE TAB 10 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *ADHESIVE BANDAGES*** *ORAL ELECTROLYTE SOLUTION*** *MULTIPLE VITAMINS W/ MINERALS TAB** PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) ALBUTEROL SULFATE TAB 4 MG *MULTIPLE VITAMINS W/ MINERALS TAB** GLYCERIN-HYPROMELLOSE-PEG 400 OPHTH SOLN 0.2-0.2-1% RALTEGRAVIR POTASSIUM CHEW TAB 100 MG (BASE EQUIV) *LANCETS*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** GLYCERIN-HYPROMELLOSE-PEG 400 OPHTH SOLN 0.2-0.2-1% LEVOTHYROXINE SODIUM TAB 112 MCG FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) TOLNAFTATE CREAM 1% *OMEGA-3 FATTY ACIDS CAP 500 MG** LEVOTHYROXINE SODIUM TAB 88 MCG ROPINIROLE HYDROCHLORIDE TAB 0.25 MG FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT) ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) NYSTATIN TOPICAL POWDER 100000 UNIT/GM GLIPIZIDE TAB ER 24HR 10 MG BACITRACIN ZINC OINT 500 UNIT/GM

Appendix F9 58 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG *LANCETS*** CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT) Y *BIOFLAVONOID PRODUCTS TAB ER** EPOPROSTENOL SODIUM FOR INJ 0.5 MG Y SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP CLOTRIMAZOLE CREAM 1% CHOLECALCIFEROL CHEW TAB 10 MCG (400 UNIT) DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML SULINDAC TAB 150 MG *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** *VITAMINS A & D CAP*** DIPHENHYDRAMINE HCL CAP 25 MG *ARTIFICIAL TEAR OPHTH SOLUTION*** SOTALOL HCL (AFIB/AFL) TAB 120 MG ASPIRIN TAB DELAYED RELEASE 81 MG *B-COMPLEX W/ C & FOLIC ACID TAB*** SENNOSIDES TAB 8.6 MG CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG DIPHENHYDRAMINE HCL TAB 25 MG *ADHESIVE BANDAGES*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT AZITHROMYCIN POWD PACK FOR SUSP 1 GM *ADHESIVE BANDAGES*** CARISOPRODOL TAB 350 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") & PSEUDOEPHEDRINE ELIXIR 1-15 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 59 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ETHOSUXIMIDE CAP 250 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** INDAPAMIDE TAB 1.25 MG DESONIDE OINT 0.05% *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** HYDROCORTISONE SOLN 1% TEZACAFTOR-IVACAFTOR 50-75 MG & IVACAFTOR 75 MG TAB TBPK Y *LANCETS*** LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *LANCETS*** CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) CHLORPHENIRAMINE MALEATE TAB 4 MG *SPECIALITY VITAMIN PRODUCT TAB** BACITRACIN OPHTH OINT 500 UNIT/GM CEPHALEXIN TAB 500 MG CEFTRIAXONE SODIUM FOR INJ 500 MG SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML Y BISMUTH SUBSALICYLATE SUSP 525 MG/15ML *MULTIPLE VITAMINS W/ MINERALS CAP** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT PERMETHRIN CREAM 5% DOCUSATE SODIUM CAP 100 MG CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV) *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *ADHESIVE BANDAGES*** LIDOCAINE PATCH 4% *MULTIPLE VITAMINS W/ MINERALS TAB** DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG Y

Appendix F9 60 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT TRIAMCINOLONE ACETONIDE OINT 0.5% ACETAMINOPHEN TAB 500 MG RUXOLITINIB PHOSPHATE TAB 10 MG (BASE EQUIVALENT) Y DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *B-COMPLEX W/ FOLIC ACID TAB ER** KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *ADHESIVE BANDAGES*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML UREA CREAM 40% FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) NALOXEGOL OXALATE TAB 25 MG (BASE EQUIVALENT) LEVONORGESTREL RELEASING IUD 14 MCG/DAY (13.5 MG TOTAL) CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) ESTRADIOL VAGINAL TAB 10 MCG OMEPRAZOLE CAP DELAYED RELEASE 10 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG HYDROCHLOROTHIAZIDE TAB 25 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG PROMETHAZINE HCL SYRUP 6.25 MG/5ML METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV) *OMEGA-3 FATTY ACIDS CAP 1000 MG** LORATADINE SYRUP 5 MG/5ML TOLNAFTATE SOLN 1% INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64" TOLNAFTATE SOLN 1% *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** ASPIRIN TAB DELAYED RELEASE 81 MG OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG Y CALCIUM CARBONATE-MAG HYDROXIDE CHEW TAB 550-110 MG

Appendix F9 61 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TAB ER 750 MG (ANTIHYPERLIPIDEMIC) *MULTIPLE VITAMINS W/ MINERALS CAP** *ADHESIVE BANDAGES*** CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG LEVOTHYROXINE SODIUM TAB 150 MCG PYRAZINAMIDE TAB 500 MG CITRATE TAB 60 MG (BASE EQUIVALENT) *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG*** *B-COMPLEX W/ C & CALCIUM TAB*** C1 ESTERASE INHIBITOR (RECOMBINANT) FOR IV INJ 2100 UNIT Y INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML METHOTREXATE SODIUM TAB 10 MG (BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS CAP** NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG CALCIUM CARBONATE-VITAMIN D TAB 500 MG-125 UNIT METRONIDAZOLE CAP 375 MG *VITAMINS A & D TAB*** IBUPROFEN TAB 200 MG MELATONIN CHEW TAB 2.5 MG SENNOSIDES TAB 15 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG Y PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-9500-15000 UNIT *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** CHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG SULFACETAMIDE SODIUM OPHTH SOLN 10% CALCIUM CARBONATE-VITAMIN D CHEW TAB 600 MG-400 UNIT *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** ENOXAPARIN SODIUM INJ 100 MG/ML HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM DIPHENHYDRAMINE HCL CAP 25 MG

Appendix F9 62 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT *LANCETS*** CIMETIDINE TAB 200 MG DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** PROMETHAZINE HCL SUPPOS 50 MG BISACODYL TAB DELAYED RELEASE 5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *BIOFLAVONOID PRODUCTS TAB ER** *MULTIPLE VITAMINS W/ MINERALS TAB** SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 8.8 MG Y CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV) *SPECIALITY VITAMIN PRODUCT TAB** FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT *MULTIPLE VITAMINS W/ MINERALS CAP** ELIGLUSTAT TARTRATE CAP 84 MG (BASE EQUIVALENT) Y SALINE NASAL SPRAY 0.65% *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** UREA CREAM 40% HYDROCORTISONE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** PREDNISOLONE SODIUM PHOSPHATE ORAL SOLN 25 MG/5ML (BASE EQ) PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT

Appendix F9 63 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *SPECIALITY VITAMIN PRODUCT TAB** ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML Y CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT DIGOXIN ORAL SOLN 0.05 MG/ML *LANCETS*** *LANCETS*** *LANCETS*** ACETAMINOPHEN TAB 500 MG *BIOFLAVONOID PRODUCTS TAB ER** PANCRELIPASE (LIP-PROT-AMYL) DR CAP 36000-114000-180000 UNIT DIPHENHYDRAMINE HCL TAB 25 MG ISOSORBIDE DINITRATE TAB 5 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *MULTIPLE VITAMINS W/ MINERALS TAB** MELATONIN TAB 3 MG HYDROCORTISONE OINT 2.5% HYLAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML Y *MULTIPLE VITAMIN TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG CRISABOROLE OINT 2% Y *LANCETS*** HYLAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% CHLORPHENIRAMINE MALEATE TAB 4 MG CHLORPHENIRAMINE MALEATE TAB 4 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *LANCETS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***

Appendix F9 64 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG PREDNISONE TAB 20 MG DOCUSATE SODIUM CAP 100 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** CARBOXYMETHYLCELLULOSE-GLYCERIN (PF) OPHTH SOLN 0.5-0.9% *RESPIRATORY THERAPY SUPPLIES - MISC** *LANCETS*** *MULTIPLE URINE TEST STRIPS*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *LANCETS*** PHENOBARBITAL TAB 60 MG GUAIFENESIN SYRUP 100 MG/5ML LISINOPRIL TAB 40 MG TRIAMCINOLONE ACETONIDE OINT 0.1% *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *PEDIATRIC MULTIPLE VITAMIN LIQ** CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA) ACETAMINOPHEN SOLN 160 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *MULTIPLE VITAMINS W/ MINERALS TAB** PROPRANOLOL HCL TAB 60 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT DOCUSATE SODIUM CAP 100 MG DOFETILIDE CAP 500 MCG (0.5 MG) Y DOCUSATE SODIUM CAP 100 MG DOXYCYCLINE HYCLATE CAP 100 MG

Appendix F9 65 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** NORETHINDRONE TAB 0.35 MG SENNOSIDES TAB 8.6 MG *VITAMINS W/ LIPOTROPICS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *VAPORIZERS*** *LANCETS*** PHENYTOIN SODIUM EXTENDED CAP 200 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** TRAMADOL HCL TAB ER 24HR 300 MG Y *MULTIPLE VITAMIN TAB** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML ADALIMUMAB PREFILLED SYRINGE KIT 20 MG/0.4ML Y CHOLECALCIFEROL TAB 10 MCG (400 UNIT) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE) FERROUS SULFATE TAB ER 142 MG (45 MG FE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** LOPERAMIDE HCL CAP 2 MG FLECAINIDE ACETATE TAB 150 MG LOPERAMIDE HCL TAB 2 MG LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG REPAGLINIDE TAB 2 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG ALMOND OIL (SWEET) LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 40 MCG/0.4ML Y ZIDOVUDINE TAB 300 MG *LANCETS*** MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)

Appendix F9 66 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** IBUPROFEN TAB 400 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/ C & FOLIC ACID TAB*** *MULTIPLE VITAMINS W/ CALCIUM TAB** AFATINIB DIMALEATE TAB 20 MG (BASE EQUIVALENT) Y *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ CALCIUM TAB** *ALCOHOL SWABS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *MULTIPLE VITAMINS W/ IRON TAB** CAPSAICIN LIQUID 0.15% *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** MELATONIN CAP 10 MG POVIDONE-IODINE SOLN 10% *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *LANCETS*** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** TEMOZOLOMIDE CAP 250 MG Y ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACKET 5 MG POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML *RESPIRATORY THERAPY SUPPLIES - MISC** *RESPIRATORY THERAPY SUPPLIES - MISC** *RESPIRATORY THERAPY SUPPLIES - MISC** RUCAPARIB CAMSYLATE TAB 300 MG (BASE EQUIVALENT) Y BENAZEPRIL HCL TAB 5 MG BUDESONIDE INHALATION SUSP 1 MG/2ML *LANCETS***

Appendix F9 67 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INDINAVIR SULFATE CAP 200 MG CYCLOPHOSPHAMIDE CAP 25 MG *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** MINOCYCLINE HCL CAP 100 MG HYDROCORTISONE TAB 10 MG SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SOLN 10-0.23(0.25)% MELATONIN TAB 5 MG ALOGLIPTIN-PIOGLITAZONE TAB 25-30 MG LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) RIVASTIGMINE TD PATCH 24HR 13.3 MG/24HR Y DIPHENHYDRAMINE HCL CAP 25 MG BISMUTH SUBSALICYLATE TAB 262 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN PRAVASTATIN SODIUM TAB 40 MG CAP 75 MG Y SENNOSIDES TAB 8.6 MG METHYLDOPA TAB 500 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT) *B-COMPLEX W/BIOTIN & FOLIC ACID CAP*** *MULTIPLE VITAMINS W/ MINERALS TAB** *SPECIALITY VITAMIN PRODUCT CAP** GLIPIZIDE TAB ER 24HR 5 MG *SPECIALITY VITAMIN PRODUCT CAP** ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV) CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT GUAIFENESIN LIQUID 100 MG/5ML GLYCOPYRROLATE TAB 2 MG HYDROCORTISONE ACETATE CREAM 1% DOXAZOSIN MESYLATE TAB 4 MG INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") HYDROCORTISONE ACETATE CREAM 1% *VITAMINS W/ LIPOTROPICS TAB**

Appendix F9 68 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TAB 1 MG *SPECIALITY VITAMIN PRODUCT TAB** BUMETANIDE TAB 2 MG HYDROCORTISONE-ALOE VERA CREAM 1% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF) SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG ACETAMINOPHEN DISINTEGRATING TAB 160 MG FEXOFENADINE HCL TAB 60 MG NAPROXEN SODIUM TAB 220 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT DIPHENHYDRAMINE HCL TAB 25 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4% *MULTIPLE VITAMINS W/ MINERALS CAP** SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT) Y DIPHENHYDRAMINE HCL CAP 25 MG LEVOCARNITINE CAP 500 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** LEVOTHYROXINE SODIUM TAB 137 MCG *LANCETS*** ACETAMINOPHEN TAB 500 MG METFORMIN HCL TAB ER 24HR 500 MG INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30) *LANCETS*** CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/ C & E TAB*** KETOROLAC TROMETHAMINE TAB 10 MG MECLIZINE HCL TAB 12.5 MG *SPECIALITY VITAMIN PRODUCT CAP**

Appendix F9 69 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ADHESIVE BANDAGES*** DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG BISMUTH SUBSALICYLATE SUSP 525 MG/15ML DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG PSEUDOEPHEDRINE HCL TAB 30 MG HCL TAB 10 MG (BASE EQUIVALENT) METHIMAZOLE TAB 5 MG POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM *LANCETS*** CHLORPHENIRAMINE MALEATE TAB 4 MG *B-COMPLEX VITAMIN SUBLINGUAL LIQUID** TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT) *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** IBUPROFEN CAP 200 MG *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** CETIRIZINE HCL TAB 10 MG *LANCETS*** HYDROCORTISONE CREAM 1% DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML ACETAMINOPHEN TAB ER 650 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CIMETIDINE TAB 200 MG POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM *COD LIVER OIL CAP*** CALCIUM ASCORBATE TAB 500 MG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB**

Appendix F9 70 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** ACARBOSE TAB 100 MG *LANCETS*** SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 4 MG Y FEXOFENADINE HCL TAB 180 MG HYDROCORTISONE PERIANAL CREAM 2.5% *MULTIPLE VITAMINS W/ MINERALS CAP** DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG PHENOBARBITAL ELIXIR 20 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG CALCIUM CARBONATE (ANTACID) CHEW TAB 1177 MG (471 MG CA) ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML) CHLORPHENIRAMINE MALEATE TAB 4 MG POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ POVIDONE-IODINE SOLN 7.5% *LANCETS*** BACITRACIN OINT 500 UNIT/GM POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP GLIPIZIDE-METFORMIN HCL TAB 5-500 MG *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMIN TAB** ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG BISACODYL SUPPOS 10 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** LOPERAMIDE HCL TAB 2 MG ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML) NYSTATIN TOPICAL POWDER 100000 UNIT/GM SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)

Appendix F9 71 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs SPIRONOLACTONE TAB 50 MG LOPERAMIDE HCL CAP 2 MG TIMOLOL MALEATE TAB 20 MG LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE) Y WARFARIN SODIUM TAB 2 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) CLOTRIMAZOLE CREAM 1% FOLIC ACID TAB 400 MCG *ALCOHOL SWABS*** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG *LANCETS*** IMIQUIMOD CREAM 5% DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG GUAIFENESIN LIQUID 100 MG/5ML *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** AMOXICILLIN (TRIHYDRATE) CHEW TAB 125 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** HYDROCORTISONE CREAM 1% CAPSAICIN CREAM 0.1% *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS CAP** ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV) Y POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM *MULTIPLE VITAMINS W/ MINERALS TAB** FOLIC ACID-VITAMIN B6- TAB 2.5-25-1 MG THIAMINE HCL TAB 100 MG *MASKS*** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 120-1200 MG CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML

Appendix F9 72 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG) *OMEGA-3 FATTY ACIDS CAP 1000 MG** CEFDINIR FOR SUSP 125 MG/5ML GLIPIZIDE TAB ER 24HR 5 MG MEFLOQUINE HCL TAB 250 MG ROPINIROLE HYDROCHLORIDE TAB 0.5 MG *LANCETS*** DEXTRAN 70-HYPROMELLOSE (PF) OPHTH SOLN 0.1-0.3% *MULTIPLE VITAMINS W/ MINERALS TAB** SULINDAC TAB 200 MG *MASKS*** SALINE NASAL SPRAY 0.65% *MULTIPLE VITAMINS W/ MINERALS TAB** PROBENECID TAB 500 MG *B-COMPLEX W/ C & FOLIC ACID TAB 1 MG*** SENNOSIDES TAB 25 MG CLOTRIMAZOLE VAGINAL CREAM 2% PYRIDOXINE HCL TAB 50 MG SOTALOL HCL (AFIB/AFL) TAB 80 MG *ADHESIVE BANDAGES*** IBUPROFEN SUSP 100 MG/5ML CERITINIB TAB 150 MG Y ALBUTEROL SULFATE SYRUP 2 MG/5ML *LANCETS*** ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACKET 10 MG SALINE NASAL SPRAY 0.65% ALBUTEROL SULFATE TAB 2 MG *MULTIPLE VITAMINS W/ MINERALS CAP** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML MELATONIN SL TAB 10 MG PROCHLORPERAZINE SUPPOS 25 MG *LANCETS*** MICONAZOLE NITRATE VAGINAL SUPPOS 200 MG

Appendix F9 73 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *PRENATAL W/O A W/ FE CARBONYL-FE GLUC-DSS-FA TAB 27-1MG*** ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT) *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *PRENAT W/O A W/FECBN-FEGLU-FA TAB 20-1 MG & VIT B6 TAB PAK* EFAVIRENZ TAB 600 MG BUDESONIDE NASAL SUSP 32 MCG/ACT FLUOCINONIDE CREAM 0.05% GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML *MULTIPLE VITAMIN TAB** CLONIDINE TD PATCH WEEKLY 0.3 MG/24HR SILDENAFIL CITRATE TAB 20 MG Y *VITAMINS W/ LIPOTROPICS TAB** CALCIUM-MAGNESIUM-ZINC TAB 333-133-8.3 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *COD LIVER OIL*** LAMIVUDINE-TENOFOVIR DISOPROXIL FUMARATE TAB 300-300 MG *MULTIPLE VITAMINS W/ MINERALS TAB** HYDROCORTISONE CREAM 1% TOLNAFTATE SOLN 1% ACETAMINOPHEN TAB ER 650 MG *LACTOBACILLUS CAP** *BIOFLAVONOID PRODUCTS TAB** PREDNISONE TAB 50 MG MICONAZOLE NITRATE OINTMENT 2% DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG METHOTREXATE SOLN PF AUTO-INJECTOR 30 MG/0.6ML Y CELECOXIB CAP 50 MG Y ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** DABRAFENIB MESYLATE CAP 75 MG (BASE EQUIVALENT) Y *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 74 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.5-25-1 MG BENZOYL PEROXIDE LIQ 5% SOTALOL HCL TAB 80 MG FEXOFENADINE HCL TAB 180 MG *BIOFLAVONOID PRODUCTS CAP** TAB 40 MG CIMETIDINE TAB 800 MG ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML Y *OMEGA-3 FATTY ACIDS CAP 500 MG** NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV) Y DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG ERTUGLIFLOZIN L-PYROGLUTAMIC ACID TAB 15 MG (BASE EQUIV) Y SACUBITRIL-VALSARTAN TAB 24-26 MG FOSAMPRENAVIR CALCIUM SUSP 50 MG/ML (BASE EQUIV) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG MERCAPTOPURINE TAB 50 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CARISOPRODOL TAB 250 MG FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE) *MULTIPLE VITAMINS W/ MINERALS TAB** *SPECIALITY VITAMIN PRODUCT TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** GUAIFENESIN TAB 200 MG HYDROCORTISONE-ALOE VERA CREAM 1% DICLOXACILLIN SODIUM CAP 500 MG OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG Y *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML*** *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") LEVOTHYROXINE SODIUM TAB 75 MCG

Appendix F9 75 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs SENNA TEA BAG 30 MG DARUNAVIR ETHANOLATE TAB 800 MG (BASE EQUIV) LORATADINE TAB 10 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG CHOLECALCIFEROL DROPS 10 MCG/0.03ML (400 UNIT/0.03ML) CINACALCET HCL TAB 60 MG (BASE EQUIV) Y CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) ACETAMINOPHEN TAB ER 650 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML CEFTRIAXONE SODIUM FOR INJ 250 MG PENICILLIN G BENZATHINE INTRAMUSCULAR SUSP 600000 UNIT/ML *RESPIRATORY THERAPY SUPPLIES - MISC** CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT) Y LOPERAMIDE HCL TAB 2 MG BENZOYL PEROXIDE CREAM 10% *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG ACETAMINOPHEN LIQUID 160 MG/5ML *LANCETS*** DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) *LANCETS*** BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1% ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV) *DIAPER RASH PRODUCTS - OINTMENT** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML CEFTOLOZANE-TAZOBACTAM FOR INJ 1.5 GM (1-0.5 GM) Y *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS ORAL POWDER**

Appendix F9 76 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CHOLECALCIFEROL DROPS 50 MCG/0.03ML (2000 UNIT/0.03ML) INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") LORATADINE CHEW TAB 5 MG SENNOSIDES TAB 25 MG CAPSAICIN-MENTHOL GEL 0.025-10% DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG *LANCETS*** NORETHINDRONE TAB 0.35 MG *MULTIPLE VITAMINS W/ MINERALS POWDER** *MULTIPLE VITAMINS W/ MINERALS POWDER** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG AZITHROMYCIN TAB 500 MG BACITRACIN-POLYMYXIN B OPHTH OINT CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) WATER FOR INJECTION *B-COMPLEX W/ FOLIC ACID TAB** NEVIRAPINE SUSP 50 MG/5ML *MASKS*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML LEVOTHYROXINE SODIUM TAB 175 MCG *RESPIRATORY THERAPY SUPPLIES - MISC** INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.5 MG/ML*** *MASKS*** *LANCETS*** CAP 100 MG METHOTREXATE SODIUM TAB 7.5 MG (BASE EQUIV) ASPIRIN CHEW TAB 81 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *COD LIVER OIL*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 77 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML) Y ACETAMINOPHEN TAB 325 MG CAPSAICIN LIQUID 0.15% LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG CALCIUM CARBONATE-VITAMIN D TAB 250 MG-125 UNIT NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) SIMETHICONE CHEW TAB 125 MG GALANTAMINE HYDROBROMIDE TAB 12 MG DOCUSATE SODIUM SYRUP 60 MG/15ML DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG Y *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS ORAL POWDER** INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") PROPAFENONE HCL TAB 300 MG TOLNAFTATE AEROSOL POW 1% *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** HYDROCORTISONE TAB 5 MG *LACTOBACILLUS CAP** HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG Y METHOTREXATE SOLN PF AUTO-INJECTOR 12.5 MG/0.25ML Y CAPTOPRIL TAB 12.5 MG CHLORHEXIDINE GLUCONATE DRESSING HYDROCORTISONE LOTION 1% *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS ORAL POWDER** *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS ORAL POWDER** BICTEGRAVIR-EMTRICITABINE-TENOFOVIR AF TAB 50-200-25 MG ACARBOSE TAB 50 MG INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT) Y PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG CETIRIZINE HCL TAB 10 MG

Appendix F9 78 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG LISINOPRIL TAB 2.5 MG *B-COMPLEX W/ C & FOLIC ACID TAB*** CONDOMS LATEX LUBRICATED *BREWERS YEAST POWDER*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN LORATADINE SYRUP 5 MG/5ML *B-COMPLEX W/ C TAB** MELATONIN TABLET DISINTEGRATING 5 MG *URINE GLUCOSE-KETONES TEST STRIPS*** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG TREPROSTINIL DIOLAMINE TAB ER 0.25 MG (BASE EQUIV) Y ACETAMINOPHEN CHEW TAB 160 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *MULTIPLE VITAMINS W/ MINERALS TAB** LORATADINE TAB 10 MG NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") PHENOBARBITAL TAB 100 MG FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *COD LIVER OIL CAP*** *MULTIPLE VITAMINS W/ MINERALS TAB** BISACODYL TAB DELAYED RELEASE 5 MG *LANCETS*** ACETAMINOPHEN CHEW TAB 160 MG *LANCETS***

Appendix F9 79 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** VENETOCLAX TAB 10 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** BISMUTH SUBSALICYLATE CHEW TAB 262 MG CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT RITONAVIR TAB 100 MG *OMEGA-3 FATTY ACIDS CAP 500 MG** PROMETHAZINE-PHENYLEPHRINE-CODEINE SYRUP 6.25-5-10 MG/5ML *BIOFLAVONOID PRODUCTS CAP** NIACIN W/ INOSITOL CAP 400-100 MG *LANCETS*** CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT) LOVASTATIN TAB 10 MG LEVOTHYROXINE SODIUM TAB 200 MCG *B-COMPLEX W/BIOTIN & FOLIC ACID CAP*** THIAMINE HCL TAB 100 MG TAB 60 MG FLECAINIDE ACETATE TAB 100 MG DOXAZOSIN MESYLATE TAB 8 MG CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN NEVIRAPINE TAB 200 MG BISACODYL TAB DELAYED RELEASE 5 MG BISMUTH SUBSALICYLATE TAB 262 MG MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV) CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) PILOCARPINE HCL TAB 7.5 MG SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML) Y *OMEGA-3 FATTY ACIDS CAP 1360 MG** *RESPIRATORY THERAPY SUPPLIES - MISC**

Appendix F9 80 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** LIDOCAINE PATCH 4% SENNOSIDES TAB 25 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-200 UNIT *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *COD LIVER OIL CAP*** *LANCETS*** *LANCETS*** *LANCETS*** FAMOTIDINE TAB 20 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMIN TAB** EMPAGLIFLOZIN TAB 25 MG Y *ADHESIVE BANDAGES - PADS*** HYDROCORTISONE CREAM 0.5% ALPHA1-PROTEINASE INHIBITOR (HUMAN) FOR IV SOLN 1000 MG Y FEXOFENADINE HCL TAB 180 MG CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) *ADHESIVE BANDAGES*** *B-COMPLEX W/ C & FOLIC ACID TAB*** IBUPROFEN CHEW TAB 100 MG *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *LANCETS*** SELENIUM SULFIDE LOTION 1% DOFETILIDE CAP 250 MCG (0.25 MG) Y *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** NORETHINDRONE TAB 0.35 MG HYDROXYPROGESTERONE CAPROATE IM IN OIL 250 MG/ML Y TRAMADOL HCL TAB 50 MG Y CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) *BIOFLAVONOID PRODUCTS TAB** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32")

Appendix F9 81 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** *OMEGA-3 FATTY ACIDS CAP 1200 MG** FEXOFENADINE HCL TAB 180 MG ACETAMINOPHEN DISINTEGRATING TAB 80 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG ASPIRIN TAB DELAYED RELEASE 81 MG *LANCETS*** *ALCOHOL SWABS*** NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** *LACTOBACILLUS REUTERI LIQUID** *ADHESIVE BANDAGES*** METHYLDOPA TAB 250 MG CHLORTHALIDONE TAB 50 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** DICLOFENAC SODIUM TAB ER 24HR 100 MG GLIPIZIDE TAB ER 24HR 2.5 MG *SPECIALITY VITAMIN PRODUCT TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML LORATADINE SYRUP 5 MG/5ML *OMEGA-3 FATTY ACIDS CAP 1000 MG** *LANCETS*** CALCIUM CARBONATE-CHOLECALCIFEROL CHEW TAB 500 MG-400 UNIT CELECOXIB CAP 100 MG Y CETIRIZINE HCL TAB 10 MG *MASKS*** *SPECIALITY VITAMIN PRODUCT COMBO PAK** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG *SPECIALITY VITAMIN PRODUCT COMBO PAK** *ADHESIVE BANDAGES*** *SPECIALITY VITAMIN PRODUCT CAP**

Appendix F9 82 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT) *B-COMPLEX W/ C TAB** TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1% FLUTICASONE-SALMETEROL AER POWDER BA 113-14 MCG/ACT IBUPROFEN CAP 200 MG CARBOXYMETHYLCELLULOSE SODIUM OPHTH GEL 1% NELFINAVIR MESYLATE TAB 625 MG *MASKS*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** DIPHENHYDRAMINE HCL CAP 25 MG *LANCETS*** CICLOPIROX OLAMINE SUSP 0.77% (BASE EQUIV) ASPIRIN SUPPOS 300 MG POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% ERGOCALCIFEROL TAB 10 MCG (400 UNIT) *BIOFLAVONOID PRODUCTS TAB ER** *MULTIPLE VITAMINS W/ MINERALS TAB** PHENOBARBITAL TAB 30 MG DIPHENHYDRAMINE HCL TAB 25 MG INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") RIVASTIGMINE TD PATCH 24HR 9.5 MG/24HR Y *CALAMINE LOTION*** PALBOCICLIB CAP 100 MG Y TRANDOLAPRIL TAB 1 MG DOCUSATE SODIUM CAP 100 MG POLYVINYL ALCOHOL-POVIDONE (PF) OPHTH SOLN 1.4-0.6% CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA) CARBAMIDE PEROXIDE 6.5% OTIC SOLN ISOSORBIDE DINITRATE TAB 10 MG *LANCETS*** HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 83 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ABACAVIR SULFATE TAB 300 MG (BASE EQUIV) TAB 2.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** GENTAMICIN SULFATE OINT 0.1% PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB 600-50-300 MG GLUCOSE BLOOD TEST STRIP CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG *ADHESIVE BANDAGES*** *SPECIALITY VITAMIN PRODUCT TAB** BENZOYL PEROXIDE LIQ 10% GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG *RESPIRATORY THERAPY SUPPLIES - MISC** NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG *SPECIALITY VITAMIN PRODUCT CAP** *LACTOBACILLUS REUTERI LIQUID** GENTAMICIN SULFATE OPHTH SOLN 0.3% DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG *LACTOBACILLUS REUTERI STRAW** *LACTOBACILLUS REUTERI CHEW TAB** *BIOFLAVONOID PRODUCTS TAB** *LANCETS*** POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT BISMUTH SUBSALICYLATE SUSP 525 MG/15ML OMEPRAZOLE CAP DELAYED RELEASE 20 MG RUCAPARIB CAMSYLATE TAB 250 MG (BASE EQUIVALENT) Y *LACTOBACILLUS REUTERI CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 84 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DIPHENHYDRAMINE HCL CAP 25 MG METHIMAZOLE TAB 10 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG IBUPROFEN TAB 100 MG *LANCETS*** IBUPROFEN SUSP 100 MG/5ML DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG CEFUROXIME AXETIL TAB 500 MG SENNOSIDES SYRUP 8.8 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** CETIRIZINE HCL TAB 10 MG *B-COMPLEX W/ C & E + ZN TAB*** SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF) ASPIRIN TAB DELAYED RELEASE 325 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** FEXOFENADINE HCL TAB 180 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) ISOTRETINOIN CAP 10 MG Y *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *LANCETS*** *OMEGA-3 FATTY ACIDS CAP 1200 MG** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-200 UNIT DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG DILTIAZEM HCL COATED BEADS TAB ER 24HR 420 MG LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) HYDROCORTISONE CREAM 1% *LANCETS*** SODIUM FLUORIDE GEL 1.1% (0.5% F) SENNOSIDES CHEW TAB 15 MG

Appendix F9 85 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACYCLOVIR TAB 400 MG CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG *LANCETS*** SIMETHICONE CAP 125 MG IVACAFTOR PACKET 75 MG Y DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG *LANCETS*** *ADHESIVE BANDAGES*** CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) ASPIRIN TAB DELAYED RELEASE 81 MG *LANCETS*** PANCRELIPASE (LIP-PROT-AMYL) DR CAP 5000-17000-24000 UNIT LIDOCAINE HCL SOLN 4% *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** SIMETHICONE CHEW TAB 80 MG SODIUM CHLORIDE SOLN NEBU 3% *LACTOBACILLUS CAP** LINEZOLID TAB 600 MG Y FLUTICASONE PROPIONATE AER POW BA 100 MCG/BLISTER PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG FLUTICASONE PROPIONATE AER POW BA 100 MCG/BLISTER BISMUTH SUBSALICYLATE SUSP 262 MG/15ML ETODOLAC TAB 500 MG SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 6 MG Y *LANCETS*** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** HYDROCORTISONE CREAM 2.5% NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG LIFITEGRAST OPHTH SOLN 5% Y TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% ACETAMINOPHEN TAB ER 650 MG

Appendix F9 86 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *SPECIALITY VITAMIN PRODUCT CAP** BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG AZATHIOPRINE TAB 100 MG SELEXIPAG TAB 800 MCG Y HYDROMORPHONE HCL TAB 8 MG Y TIMOLOL MALEATE TAB 5 MG HYDROCORTISONE LOTION 1% SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) HYDROCORTISONE-ALOE VERA CREAM 1% ASPIRIN TAB 325 MG CETIRIZINE HCL TAB 10 MG BACITRACIN-POLYMYXIN B OPHTH OINT *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ IRON TAB** FERROUS SULFATE TAB ER 142 MG (45 MG FE EQUIVALENT) EVEROLIMUS TAB 5 MG Y *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-125 UNIT POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-125 UNIT *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** ERYTHROMYCIN OPHTH OINT 5 MG/GM MEMANTINE HCL ORAL SOLUTION 2 MG/ML IBUPROFEN SUSP 100 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML ALOGLIPTIN-PIOGLITAZONE TAB 12.5-15 MG *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *LANCETS*** *LANCETS*** ASPIRIN CHEW TAB 81 MG GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG

Appendix F9 87 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs BENAZEPRIL HCL TAB 40 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *COD LIVER OIL*** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *DIAPHRAGMS*** IVERMECTIN TAB 3 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG OXYCODONE HCL CAP 5 MG Y *ADHESIVE BANDAGES*** CALCIPOTRIENE SOLN 0.005% (50 MCG/ML) Y *LANCETS*** TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER 40 MG/GM NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS PACK** *RESPIRATORY THERAPY SUPPLIES - MISC** *LANCETS*** MELATONIN TAB 3 MG IBUPROFEN TAB 200 MG INSULIN LISPRO SOLN PEN-INJECTOR 100 UNIT/ML (1 UNIT DIAL) *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG DIPHENHYDRAMINE HCL TAB 25 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** METHOTREXATE SODIUM TAB 5 MG (BASE EQUIV) LEVOTHYROXINE SODIUM TAB 50 MCG PENICILLIN G BENZATHINE INTRAMUSCULAR SUSP 1200000 UNIT/2ML *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 325 MG HYDROCORTISONE CREAM 1% DOFETILIDE CAP 125 MCG (0.125 MG) Y

Appendix F9 88 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ANAGRELIDE HCL CAP 0.5 MG *SPECIALITY VITAMIN PRODUCT CAP** *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** *LANCETS*** CLINDAMYCIN PHOSPHATE LOTION 1% *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** ASPIRIN CHEW TAB 81 MG DARUNAVIR ETHANOLATE SUSP 100 MG/ML (BASE EQUIV) DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML ENOXAPARIN SODIUM INJ 30 MG/0.3ML SIMETHICONE ORAL STRIP 62.5 MG *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 480 MCG/0.8ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** VALACYCLOVIR HCL TAB 500 MG FERROUS SULFATE DRIED TAB ER 45 MG (FE EQUIVALENT) *LACTOBACILLUS CHEW TAB** BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1% CHLORHEXIDINE GLUCONATE LIQUID 4% *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% GUAIFENESIN LIQUID 100 MG/5ML *VAPORIZERS*** *OMEGA-3 FATTY ACIDS CAP 500 MG** DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG *MULTIPLE VITAMINS W/ MINERALS TAB** OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG Y CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) *LANCETS*** DESONIDE LOTION 0.05% DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML AZITHROMYCIN TAB 250 MG LENALIDOMIDE CAP 20 MG Y

Appendix F9 89 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs AZITHROMYCIN FOR SUSP 200 MG/5ML SIMETHICONE CHEW TAB 125 MG *B-COMPLEX W/ FOLIC ACID TAB** CHLORAMBUCIL TAB 2 MG CLARITHROMYCIN FOR SUSP 125 MG/5ML FERROUS SULFATE DRIED TAB ER 45 MG (FE EQUIVALENT) GUAIFENESIN TAB 400 MG RIVAROXABAN TAB STARTER THERAPY PACK 15 MG & 20 MG MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML) *SPECIALITY VITAMIN PRODUCT TAB** LEVOCARNITINE (DIETARY) TAB 330 MG METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV) RIFAMPIN CAP 300 MG NORETHINDRONE TAB 0.35 MG TERCONAZOLE VAGINAL SUPPOS 80 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *SPECIALITY VITAMIN PRODUCT COMBO PAK** DIPHENHYDRAMINE HCL CAP 25 MG POTASSIUM CHLORIDE TAB ER 10 MEQ INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") *LACTOBACILLUS RHAMNOSUS (GG) LIQUID** AMOXICILLIN (TRIHYDRATE) TAB 875 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DOCUSATE SODIUM CAP 100 MG LOVASTATIN TAB 20 MG *SPECIALITY VITAMIN PRODUCT EFFER TAB** *MULTIPLE VITAMINS W/ MINERALS PACK** CHLORHEXIDINE GLUCONATE SOLN 4% FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML GLIPIZIDE TAB ER 24HR 10 MG PSEUDOEPHEDRINE W/ COD-GG SOLN 30-10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** BISACODYL TAB DELAYED RELEASE 5 MG

Appendix F9 90 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs EVOLOCUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 140 MG/ML Y TICAGRELOR TAB 90 MG TIMOLOL MALEATE OPHTH SOLN 0.25% PHENAZOPYRIDINE HCL TAB 100 MG FERROUS SULFATE TAB 27 MG (ELEMENTAL FE) *PRENATAL VIT W/ FE FUM-METHYLFOLATE-FA TAB 27-0.6-0.4 MG*** DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG DICLOXACILLIN SODIUM CAP 250 MG ACETAMINOPHEN DISINTEGRATING TAB 160 MG *ACETIC ACID VAGINAL SOLUTION** CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT NEVIRAPINE SUSP 50 MG/5ML *BIOFLAVONOID PRODUCTS TAB** MELATONIN TAB 10 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** IBUPROFEN SUSP 40 MG/ML *ADHESIVE BANDAGES*** *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML PROPRANOLOL HCL TAB 40 MG NONOXYNOL-9 GEL 2% TAB 250 MG Y ASPIRIN TAB DELAYED RELEASE 325 MG *MULTIPLE VITAMINS W/ MINERALS TAB** BISMUTH SUBSALICYLATE CHEW TAB 262 MG TOLVAPTAN TAB 30 MG Y *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *MULTIPLE VITAMINS W/ MINERALS CAP** FAMOTIDINE TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 91 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CITRATE-VITAMIN D TAB 200 MG-250 UNIT (ELEMENTAL CA) *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 81 MG NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** POLYVINYL ALCOHOL-POVIDONE OPHTH SOLN 5-6 MG/ML (0.5-0.6%) *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES TAB 15 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/15ML IBUPROFEN CAP 200 MG *SPECIALITY VITAMIN PRODUCT TAB** LORATADINE CAP 10 MG ISOTRETINOIN CAP 30 MG Y NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG SENNOSIDES SYRUP 8.8 MG/5ML INTERFERON BETA-1A AUTO-INJ 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML Y DOCUSATE SODIUM LIQUID 150 MG/15ML REPAGLINIDE TAB 0.5 MG PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG DILTIAZEM HCL CAP ER 24HR 240 MG *MULTIPLE VITAMINS W/ MINERALS TAB** RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT) Y *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** FLECAINIDE ACETATE TAB 50 MG CROMOLYN SODIUM NASAL AEROSOL SOLN 5.2 MG/ACT (4%) GUAIFENESIN TAB ER 12HR 1200 MG SIMETHICONE LIQUID 40 MG/0.6ML EFAVIRENZ CAP 50 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *ADHESIVE BANDAGES*** EFAVIRENZ-LAMIVUDINE-TENOFOVIR DF TAB 400-300-300 MG ACETAMINOPHEN ELIXIR 160 MG/5ML

Appendix F9 92 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM *B-COMPLEX VITAMIN CAP** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *OMEGA-3 FATTY ACIDS CAP 1000 MG** DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 500 MCG/ML Y *PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB & DHA CAP 250 MG PACK* *LANCETS*** *MULTIPLE VITAMIN TAB** NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN *MULTIPLE VITAMIN TAB** CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2% ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) *B-COMPLEX W/ C & CALCIUM TAB*** NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") ASPIRIN CHEW TAB 81 MG FOSINOPRIL SODIUM TAB 10 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG *LACTOBACILLUS CAP** IBUPROFEN CAP 200 MG FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE METRONIDAZOLE CREAM 0.75% NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP HYOSCYAMINE SULFATE SOLN 0.125 MG/ML CALCIUM CARBONATE TAB 1500 MG (600 MG ELEMENTAL CA) *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** DIPHENHYDRAMINE HCL (SLEEP) TAB 50 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT FERROUS SULFATE TAB ER 142 MG (45 MG FE EQUIVALENT) CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG

Appendix F9 93 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** CHOLECALCIFEROL TAB 125 MCG (5000 UNIT) ASPIRIN TAB DELAYED RELEASE 81 MG REGORAFENIB TAB 40 MG Y TERCONAZOLE VAGINAL CREAM 0.8% DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) CLINDAMYCIN PHOSPHATE GEL 1% ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML Y GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML MEDROXYPROGESTERONE ACETATE TAB 2.5 MG CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG *CONDOMS - MALE*** NORETHINDRONE TAB 0.35 MG *MULTIPLE VITAMINS W/ IRON TAB** EMPAGLIFLOZIN TAB 10 MG Y PHENOBARBITAL TAB 32.4 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG SIMETHICONE SUSP 40 MG/0.6ML *OMEGA-3 FATTY ACIDS CAP 1000 MG** *SPECIALITY VITAMIN PRODUCT TAB**

Appendix F9 94 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ADHESIVE BANDAGES*** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG *ADHESIVE BANDAGES*** CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ *SPECIALITY VITAMIN PRODUCT CAP** *RESPIRATORY THERAPY SUPPLIES - MISC** *ADHESIVE BANDAGES*** SENNOSIDES TAB 8.6 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG FAMOTIDINE TAB 20 MG FAMOTIDINE TAB 20 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LACTOBACILLUS RHAMNOSUS (GG) PACKET** TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG *ADHESIVE BANDAGES - PADS*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *LANCETS*** *COD LIVER OIL CAP*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *ADHESIVE BANDAGES*** NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG CEFPROZIL TAB 500 MG *MULTIPLE VITAMINS W/ MINERALS TAB** HYOSCYAMINE SULFATE TAB 0.125 MG GUAIFENESIN LIQUID 100 MG/5ML LEVOTHYROXINE SODIUM TAB 75 MCG PRASUGREL HCL TAB 10 MG (BASE EQUIV)

Appendix F9 95 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ IRON TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** DOCUSATE SODIUM CAP 100 MG *VITAMINS A & D CAP*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT LUMACAFTOR-IVACAFTOR TAB 200-125 MG Y DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML ACETAMINOPHEN TAB 500 MG SENNOSIDES TAB 8.6 MG HALOBETASOL PROPIONATE LOTION 0.01% Y *MULTIPLE VITAMINS W/ MINERALS TAB** DIPHENHYDRAMINE HCL CAP 25 MG NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML) DESMOPRESSIN ACETATE TAB 0.2 MG Y *ORAL ELECTROLYTE SOLUTION*** *MULTIPLE VITAMINS W/ MINERALS TAB** WARFARIN SODIUM TAB 2.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** BENZOYL PEROXIDE GEL 5% *CONDOMS - MALE*** *CONDOMS - FEMALE*** *SPECIALITY VITAMIN PRODUCT EFFER TAB** *LANCETS*** ASPIRIN CHEW TAB 81 MG WATER FOR IV INJECTION *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS PACK** DICYCLOMINE HCL ORAL SOLN 10 MG/5ML PANCRELIPASE (LIP-PROT-AMYL) DR CAP 25000-79000-105000 UNIT TOBRAMYCIN NEBU SOLN 300 MG/4ML Y

Appendix F9 96 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *RESPIRATORY THERAPY SUPPLIES - MISC** HYDROCORTISONE SOLN 1% HYDROCORTISONE CREAM 1% *SPECIALITY VITAMIN PRODUCT CAP** SODIUM OXYBATE ORAL SOLUTION 500 MG/ML Y RUCAPARIB CAMSYLATE TAB 200 MG (BASE EQUIVALENT) Y *ADHESIVE BANDAGES*** DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** BUDESONIDE INHALATION SUSP 0.25 MG/2ML NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG NAFARELIN ACETATE NASAL SOLN 2 MG/ML (200 MCG/ACT) (BASE EQ) *LANCETS*** PERMETHRIN AEROSOL 0.5% *LANCETS*** *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS LIQUID** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 282-87-25 MG/5ML PHENOBARBITAL TAB 64.8 MG *MULTIPLE VITAMINS W/ MINERALS CAP** GLUCOSE BLOOD TEST STRIP *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** *LACTOBACILLUS CAP** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *ARTIFICIAL TEAR OPHTH SOLUTION*** *SPECIALITY VITAMIN PRODUCT EFFER TAB** *LANCETS*** DEXAMETHASONE TAB 6 MG INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG *B-COMPLEX VITAMIN TAB**

Appendix F9 97 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACETAMINOPHEN SUSP 160 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** CONDOMS LATEX LUBRICATED *LANCETS*** PSEUDOEPHEDRINE HCL TAB 30 MG *MULTIPLE VITAMIN TAB** PROPRANOLOL HCL ORAL SOLN 40 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** TOLNAFTATE CREAM 1% *B-COMPLEX W/ C & FOLIC ACID TAB*** DOXAZOSIN MESYLATE TAB 1 MG BUMETANIDE TAB 0.5 MG LEVOCARNITINE (DIETARY) ORAL SOLN 1 GM/10ML BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1% SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/ C TAB** *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** SALINE NASAL SPRAY 0.65% FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 24HR 180-240 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG ALIROCUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/ML Y LEFLUNOMIDE TAB 20 MG CONDOMS LATEX LUBRICATED *LANCETS***

Appendix F9 98 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CHLORHEXIDINE GLUCONATE SOLN 2% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *LANCETS*** ISOTRETINOIN CAP 40 MG Y LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) NIRAPARIB TOSYLATE CAP 100 MG (BASE EQUIVALENT) Y ACETAMINOPHEN TAB 500 MG SILVER SULFADIAZINE CREAM 1% GUAIFENESIN TAB 400 MG *MICONAZOLE NITRATE VA SUPP 1200 MG & 2% CREAM & WIPES KIT* HYDROMORPHONE HCL TAB 4 MG Y LANREOTIDE ACETATE EXTENDED RELEASE INJ 60 MG/0.2ML Y IBUPROFEN TAB 200 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *LANCETS*** *ORAL ELECTROLYTE SOLUTION*** *LANCETS*** *LANCETS*** *ADHESIVE BANDAGES*** ACETAMINOPHEN CHEW TAB 160 MG INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG DICLOFENAC SODIUM GEL 1% SOFOSBUVIR-VELPATASVIR TAB 400-100 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LANCETS*** PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT) SODIUM FLUORIDE CREAM 1.1%

Appendix F9 99 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACYCLOVIR TAB 800 MG BENAZEPRIL HCL TAB 20 MG *SPECIALITY VITAMIN PRODUCT TAB** DOLUTEGRAVIR SODIUM-LAMIVUDINE TAB 50-300 MG (BASE EQ) DULAGLUTIDE SOLN PEN-INJECTOR 0.75 MG/0.5ML Y FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.5-25-1 MG LEVOTHYROXINE SODIUM TAB 50 MCG *LANCETS*** *ADHESIVE BANDAGES*** *LANCETS*** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG DIPHENHYDRAMINE HCL CAP 25 MG MICONAZOLE NITRATE VAGINAL CREAM 2% *LANCETS*** *ADHESIVE BANDAGES*** CHLORPHENIRAMINE MALEATE TAB 4 MG *LANCETS*** CONDOMS LATEX LUBRICATED DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG *PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB 90 &DHA CAP 300MG PAK* *MULTIPLE VITAMINS W/ MINERALS TAB** DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG BISMUTH SUBSALICYLATE TAB 262 MG TOLNAFTATE AEROSOL POW 1% *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LANCETS*** GUANFACINE HCL TAB 2 MG *ADHESIVE BANDAGES*** OCRELIZUMAB SOLN FOR IV INFUSION 300 MG/10ML Y CONDOMS LATEX LUBRICATED *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS***

Appendix F9 100 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CONDOMS LATEX LUBRICATED *RESPIRATORY THERAPY SUPPLIES - MISC** INSULIN SYRINGE/NEEDLE U-500 0.5 ML 31G X 6MM (15/64") ACETAMINOPHEN TAB 325 MG *ORAL ELECTROLYTE SOLUTION*** LEVOTHYROXINE SODIUM TAB 100 MCG IBUPROFEN TAB 200 MG MICONAZOLE NITRATE VAGINAL CREAM 4% (200 MG/5GM) ACETAMINOPHEN TAB ER 650 MG CONDOMS LATEX LUBRICATED CONDOMS LATEX LUBRICATED LORATADINE SYRUP 5 MG/5ML *B-COMPLEX W/BIOTIN & FOLIC ACID CAP*** *BIOFLAVONOID PRODUCTS LIQUID** HYDROCORTISONE LOTION 1% *PRENAT W/O A W/FEFUM-METHFOL-FA-DHA CAP 27-0.6-0.4-300 MG** *ADHESIVE BANDAGES*** MELPHALAN TAB 2 MG CALCIUM CARBONATE-VITAMIN D CHEW TAB 600 MG-400 UNIT SEVELAMER CARBONATE TAB 800 MG Y *ADHESIVE BANDAGES*** NAPROXEN SODIUM TAB 220 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% CONDOMS LATEX LUBRICATED FERROUS FUMARATE TAB 325 MG (106 MG ELEMENTAL FE) *ALCOHOL SWABS*** KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) CONDOMS LATEX LUBRICATED WARFARIN SODIUM TAB 1 MG GRISEOFULVIN ULTRAMICROSIZE TAB 125 MG LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 101 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 30-600 MG PSEUDOEPHEDRINE HCL TAB 30 MG FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** *VITAMINS W/ LIPOTROPICS TAB** HYDROCORTISONE CREAM 1% *VAPORIZERS*** ENTECAVIR ORAL SOLN 0.05 MG/ML PHENAZOPYRIDINE HCL TAB 200 MG LIDOCAINE PATCH 4% CALCIUM CARBONATE TAB 600 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *LACTOBACILLUS RHAMNOSUS (GG) CAP** *LANCETS*** *ADHESIVE BANDAGES*** MECLIZINE HCL TAB 25 MG INSULIN LISPRO INJ 100 UNIT/ML DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *RESPIRATORY THERAPY SUPPLIES - MISC** *MULTIPLE VITAMINS W/ MINERALS TAB** ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG KETOCONAZOLE CREAM 2% HYDROCORTISONE ENEMA 100 MG/60ML *SPECIALITY VITAMIN PRODUCT CAP** CLOTRIMAZOLE CREAM 1% CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLN 0.5% NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64" *ANTISEPTIC PRODUCTS MISC - PADS** MECLIZINE HCL TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS LIQUID**

Appendix F9 102 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** LORATADINE SYRUP 5 MG/5ML FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN TAB 2.5-25-2 MG CONDOMS LATEX LUBRICATED EPOPROSTENOL SODIUM FOR INJ 1.5 MG Y DARUNAVIR ETHANOLATE TAB 150 MG (BASE EQUIV) GUAIFENESIN LIQUID 100 MG/5ML DOCUSATE SODIUM CAP 100 MG LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML LOVASTATIN TAB 40 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT LENVATINIB CAP THERAPY PACK 3 X 4 MG (12 MG DAILY DOSE) Y CONDOMS LATEX LUBRICATED SENNOSIDES TAB 8.6 MG LAMIVUDINE-TENOFOVIR DISOPROXIL FUMARATE TAB 300-300 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** *MULTIPLE VITAMINS W/ MINERALS PACK** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG OMEPRAZOLE CAP DELAYED RELEASE 20 MG SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML TIMOLOL MALEATE OPHTH SOLN 0.5% SODIUM POLYSTYRENE SULFONATE RECTAL SUSP 30 GM/120ML RUXOLITINIB PHOSPHATE TAB 20 MG (BASE EQUIVALENT) Y GUAIFENESIN TAB ER 12HR 600 MG ETODOLAC TAB 400 MG METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *VITAMINS A & D TAB*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB**

Appendix F9 103 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs BENZOYL PEROXIDE LIQ 7% SACUBITRIL-VALSARTAN TAB 49-51 MG CYCLOSPORINE CAP 100 MG SODIUM POLYSTYRENE SULFONATE RECTAL SUSP 30 GM/120ML *LACTOBACILLUS - PACKET** POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML ASPIRIN CHEW TAB 81 MG MICONAZOLE NITRATE VAGINAL CREAM 4% (200 MG/5GM) ALOGLIPTIN-METFORMIN HCL TAB 12.5-1000 MG BISACODYL TAB DELAYED RELEASE 5 MG DIPHENHYDRAMINE HCL TAB 25 MG *DIAPER RASH PRODUCTS - CREAM** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** LEVOTHYROXINE SODIUM TAB 25 MCG PENICILLIN G BENZATHINE INTRAMUSCULAR SUSP 2400000 UNIT/4ML BISMUTH SUBSALICYLATE TAB 262 MG PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG *MULTIPLE VITAMINS W/ MINERALS PACK** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CYANOCOBALAMIN INJ 1000 MCG/ML DIPHENHYDRAMINE HCL TAB 25 MG *ADHESIVE BANDAGES*** POVIDONE-IODINE SOLN 10% TESTOSTERONE TD GEL 10MG/ACT (2%) Y *MULTIPLE VITAMINS W/ CALCIUM TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** CALCIUM W/ MAGNESIUM TAB 333-167 MG *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** ACETAMINOPHEN SOLN 160 MG/5ML

Appendix F9 104 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs BENZOYL PEROXIDE CREAM 10% CARVEDILOL TAB 25 MG REPAGLINIDE TAB 1 MG CLARITHROMYCIN FOR SUSP 250 MG/5ML ALUMINUM HYDROXIDE-MAGNESIUM TRISILICATE CHEW TAB 80-20 MG CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) *B-COMPLEX W/ C & E + ZN TAB*** EFAVIRENZ CAP 200 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML *LANCETS*** FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT POTASSIUM PHOSPHATE MONOBASIC TAB 500 MG *MULTIPLE VITAMINS W/ MINERALS TAB** SODIUM FLUORIDE GEL 1.1% (0.5% F) GUAIFENESIN SYRUP 100 MG/5ML PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** LORATADINE TAB 10 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *VITAMINS W/ LIPOTROPICS TAB** *ALCOHOL SWABS*** DOCUSATE SODIUM LIQUID 150 MG/15ML NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) IBUPROFEN SUSP 100 MG/5ML SIMETHICONE CHEW TAB 80 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG CIMETIDINE TAB 200 MG

Appendix F9 105 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DORAVIRINE-LAMIVUDINE-TENOFOVIR DF TAB 100-300-300 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML *OMEGA-3 FATTY ACIDS CAP 1000 MG** LORLATINIB TAB 100 MG Y AZITHROMYCIN FOR SUSP 100 MG/5ML ROMIDEPSIN FOR IV INJ 10 MG Y NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG FOLIC ACID TAB 400 MCG MICONAZOLE NITRATE VAGINAL APP 200 MG & 2% CREAM 9 GM KIT TERIFLUNOMIDE TAB 14 MG Y CALCIPOTRIENE OINT 0.005% Y *ADHESIVE BANDAGES*** CALCIUM CITRATE-VITAMIN D TAB 200 MG-250 UNIT (ELEMENTAL CA) CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV) NAPROXEN SODIUM TAB 220 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") ACETAMINOPHEN TAB 325 MG DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *BACTERIOSTATIC SODIUM CHLORIDE INJ SOLN 0.9%*** INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *MULTIPLE VITAMINS W/ MINERALS TAB** CHLORHEXIDINE GLUCONATE SOLN 0.12% TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT) *B-COMPLEX W/ C TAB** INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30) *MULTIPLE VITAMINS W/ MINERALS TAB** FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE) SILVER SULFADIAZINE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 106 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs HYDROCHLOROTHIAZIDE TAB 50 MG DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") CLINDAMYCIN PHOSPHATE LOTION 1% ASPIRIN TAB DELAYED RELEASE 81 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 81 MG SENNOSIDES TAB 8.6 MG CALCIUM W/ MAGNESIUM TAB 500-250 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV) Y *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** AMANTADINE HCL SYRUP 50 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *OMEGA-3 FATTY ACIDS - ORAL LIQUID** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DICLOFENAC POTASSIUM TAB 50 MG *ORAL ELECTROLYTE SOLUTION*** GUAIFENESIN LIQUID 100 MG/5ML *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV) MELATONIN TAB 3 MG SODIUM CHLORIDE SOLN NEBU 0.9% CARBAMIDE PEROXIDE 6.5% OTIC SOLN *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***

Appendix F9 107 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG TOLNAFTATE CREAM 1% DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML HYDROCORTISONE LOTION 1% *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** DOCUSATE SODIUM LIQUID 150 MG/15ML OYSTER SHELL CALCIUM TAB 500 MG CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) LEVOTHYROXINE SODIUM TAB 88 MCG CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT) HYOSCYAMINE SULFATE SL TAB 0.125 MG UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/INH CARBAMIDE PEROXIDE 6.5% OTIC SOLN PRASUGREL HCL TAB 5 MG (BASE EQUIV) *LANCETS*** *B-COMPLEX W/ FOLIC ACID TAB ER** *LANCETS*** *LANCETS*** *B-COMPLEX W/ IRON TAB** ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.8ML Y ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML DOXAZOSIN MESYLATE TAB 2 MG CALCIUM CARBONATE-VITAMIN D CAP 600 MG-200 UNIT DIPHENHYDRAMINE HCL CAP 25 MG UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/INH SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF) PERMETHRIN LOTION 1% *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML Y DESMOPRESSIN ACETATE TAB 0.1 MG Y CHOLECALCIFEROL TAB 10 MCG (400 UNIT) *OMEGA-3 FATTY ACIDS CAP 1000 MG**

Appendix F9 108 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *BIOFLAVONOID PRODUCTS TAB** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV) WARFARIN SODIUM TAB 2 MG *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** MARAVIROC TAB 25 MG *SPECIALITY VITAMIN PRODUCT TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT BENAZEPRIL HCL TAB 10 MG POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT *LANCETS*** *OMEGA-3 FATTY ACIDS CAP 435 MG** ZIDOVUDINE CAP 100 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG METOLAZONE TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT) POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MASKS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** MELATONIN TAB 300 MCG DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG ADEFOVIR DIPIVOXIL TAB 10 MG KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE) MELATONIN TABLET DISINTEGRATING 5 MG *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE SUSP 95-358 MG/15ML TOLNAFTATE AEROSOL POW 1%

Appendix F9 109 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) *LANCETS*** SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 5 MG Y *OMEGA-3 FATTY ACIDS CAP 500 MG** *LANCETS*** HYDROCHLOROTHIAZIDE TAB 12.5 MG TEMOZOLOMIDE CAP 5 MG Y FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE) PANCRELIPASE (LIP-PROT-AMYL) DR CAP 6000-19000-30000 UNIT DIPHENHYDRAMINE HCL CAP 25 MG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT) ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE SUSP 95-358 MG/15ML CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE ALOGLIPTIN-PIOGLITAZONE TAB 12.5-30 MG CHOLECALCIFEROL CAP 250 MCG (10000 UNIT) WARFARIN SODIUM TAB 7.5 MG *ALCOHOL SWABS*** TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML Y TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML Y CALCIUM CARBONATE-CHOLECALCIFEROL CHEW TAB 500 MG-600 UNIT *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *ADHESIVE BANDAGES - PADS*** SENNOSIDES TAB 25 MG IM INJ IN OIL 200 MG/ML Y NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG ACETAMINOPHEN ELIXIR 160 MG/5ML CROMOLYN SODIUM SOLN NEBU 20 MG/2ML LACTIC ACID (AMMONIUM LACTATE) LOTION 12% ALMOND OIL (SWEET) TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT)

Appendix F9 110 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CETIRIZINE HCL CAP 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** SELEXIPAG TAB 600 MCG Y ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE SUSP 95-358 MG/15ML FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE) *LANCETS*** PHENYTOIN CHEW TAB 50 MG GUAIFENESIN SYRUP 100 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 30-600 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DAPSONE TAB 100 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") GUAIFENESIN LIQUID 100 MG/5ML DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG ACETAMINOPHEN DISINTEGRATING TAB 160 MG CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) FAMOTIDINE TAB 10 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *B-COMPLEX W/ C-BIOTIN-VIT E & FOLIC ACID TAB 0.4 MG*** *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT THEOPHYLLINE TAB ER 24HR 400 MG TOLNAFTATE CREAM 1% *LANCETS*** *LANCETS*** *BIOFLAVONOID PRODUCTS CAP** GLYCERIN-HYPROMELLOSE-PEG 400 OPHTH SOLN 0.2-0.2-1% DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG TAB 5 MG Y

Appendix F9 111 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/ FOLIC ACID TAB** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *DIAPER RASH PRODUCTS - CREAM** CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML *MULTIPLE VITAMINS W/ MINERALS LIQUID** GUAIFENESIN LIQUID 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS POWDER** IBUPROFEN CHEW TAB 100 MG FAMOTIDINE TAB 10 MG *MULTIPLE VITAMINS W/ CALCIUM TAB** GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML Y ETODOLAC CAP 300 MG DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED) Y CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *B-COMPLEX VITAMIN ELIXIR** HYDROCORTISONE OINT 1% *RESPIRATORY THERAPY SUPPLIES - MISC** *CONDOMS - MALE*** CETIRIZINE HCL TAB 10 MG CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT ISOTRETINOIN CAP 20 MG Y LEVOFLOXACIN TAB 500 MG ACETAMINOPHEN TAB 500 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% HYDROCORTISONE PERIANAL CREAM 2.5% EMTRICITABINE CAPS 200 MG BENZONATATE CAP 100 MG

Appendix F9 112 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LACTOBACILLUS TAB** PLECANATIDE TAB 3 MG *MULTIPLE VITAMINS W/ MINERALS TAB** LIDOCAINE PATCH 4% OXYBUTYNIN CHLORIDE TAB 5 MG ACETAMINOPHEN ELIXIR 160 MG/5ML FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT) LIDOCAINE PATCH 4% *ADHESIVE BANDAGES*** *LANCETS*** *MULTIPLE VITAMIN CAP** *LANCETS*** DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG ACETAMINOPHEN CAP 500 MG ACETAMINOPHEN SUSP 160 MG/5ML CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) OXYCODONE-ASPIRIN TAB 4.8355-325 MG Y MELATONIN LIQUID 1 MG/ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML GUAIFENESIN TAB ER 12HR 1200 MG DRONABINOL CAP 10 MG *LANCETS*** CONDOMS LATEX NON-LUBRICATED CONDOMS LATEX NON-LUBRICATED CONDOMS LATEX NON-LUBRICATED *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C DROPS 45 MG/ML** CONDOMS LATEX NON-LUBRICATED *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** CONDOMS LATEX NON-LUBRICATED *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** ACETAMINOPHEN SUSP 160 MG/5ML *NYSTATIN ORAL POWDER*

Appendix F9 113 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-10000-14000 UNIT *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** *B-COMPLEX W/ C-ZN & FOLIC ACID TAB 0.8 MG*** ACETAMINOPHEN TAB ER 650 MG *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** BENZOYL PEROXIDE LIQ 10% IVACAFTOR PACKET 50 MG Y CONDOMS LATEX NON-LUBRICATED *MULTIPLE VITAMIN TAB** OFLOXACIN OTIC SOLN 0.3% CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG *OMEGA-3 FATTY ACIDS CAP 500 MG** BRODALUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 210 MG/1.5ML Y BISACODYL TAB DELAYED RELEASE 5 MG ACETAMINOPHEN TAB ER 650 MG *LANCETS*** *OMEGA-3 FATTY ACIDS - ORAL LIQUID** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% CHLORPHENIRAMINE MALEATE TAB 4 MG MYCOPHENOLATE MOFETIL TAB 500 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS POWDER** PERMETHRIN AEROSOL 0.5% ACETAMINOPHEN TAB ER 650 MG *MULTIPLE VITAMINS W/ MINERALS TAB** HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG MECLIZINE HCL CHEW TAB 25 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% CHOLECALCIFEROL CAP 1.25 MG (50000 UNIT) *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 114 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INTERFERON BETA-1A IM AUTO-INJECTOR KIT 30 MCG/0.5ML Y ETHAMBUTOL HCL TAB 100 MG LEVOTHYROXINE SODIUM TAB 75 MCG ACYCLOVIR SUSP 200 MG/5ML FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%) *OMEGA-3 FATTY ACIDS CAP 300 MG** GUAIFENESIN TAB 400 MG VANCOMYCIN HCL CAP 250 MG (BASE EQUIVALENT) Y *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** ISOTRETINOIN CAP 10 MG Y *ALCOHOL SWABS*** CLOTRIMAZOLE CREAM 1% LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG ASPIRIN TAB 325 MG DOCUSATE SODIUM TAB 100 MG *VITAMIN D & K TAB*** ALOGLIPTIN-METFORMIN HCL TAB 12.5-500 MG CIPROFLOXACIN HCL TAB 100 MG (BASE EQUIV) *ADHESIVE BANDAGES*** VERAPAMIL HCL TAB ER 240 MG *OMEGA-3 FATTY ACIDS CAP 500 MG** *MULTIPLE VITAMINS W/ MINERALS TAB** *OMEGA-3 FATTY ACIDS - ORAL LIQUID** DOCUSATE SODIUM CAP 100 MG PYRIDOXINE HCL TAB 50 MG HYPROMELLOSE OPHTH GEL 0.3% ASPIRIN CHEW TAB 81 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 325 MG FAMCICLOVIR TAB 500 MG

Appendix F9 115 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** GUAIFENESIN LIQUID 100 MG/5ML SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-125 UNIT *OMEGA-3 FATTY ACIDS CAP 1000 MG** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** PYRIDOXINE HCL TAB 50 MG LACTIC ACID (AMMONIUM LACTATE) LOTION 12% *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** OLIVE OIL DISOPYRAMIDE PHOSPHATE CAP 150 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT *LANCETS*** *ADHESIVE BANDAGES*** LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG SENNOSIDES TAB 8.6 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML CAPSAICIN CREAM 0.075% *B-COMPLEX W/ C TAB ER** ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML CETIRIZINE HCL ORALLY DISINTEGRATING TAB 10 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** MILNACIPRAN HCL TAB 50 MG Y CETIRIZINE HCL ORALLY DISINTEGRATING TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS LIQUID** *LANCETS*** CAP DELAYED RELEASE 15 MG

Appendix F9 116 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/ FOLIC ACID TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG ROPINIROLE HYDROCHLORIDE TAB 3 MG DENOSUMAB INJ SOLN PREFILLED SYRINGE 60 MG/ML Y *SPECIALITY VITAMIN PRODUCT TAB** BISACODYL SUPPOS 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") *LANCETS*** INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-4 MG PODOFILOX SOLN 0.5% CETIRIZINE HCL ORALLY DISINTEGRATING TAB 10 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** DIPHENHYDRAMINE HCL TAB 50 MG CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA) PROCARBAZINE HCL CAP 50 MG SIROLIMUS TAB 1 MG *LANCETS*** *SPECIALITY VITAMIN PRODUCT TAB** INSULIN REGULAR (HUMAN) INJ 500 UNIT/ML *B-COMPLEX VITAMIN TAB** BENZOYL PEROXIDE GEL 10% PSEUDOEPHEDRINE HCL TAB 30 MG AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY) SENNOSIDES CHEW TAB 15 MG SELEXIPAG TAB 1000 MCG Y *MULTIPLE VITAMINS W/ MINERALS TAB** HYDROCORTISONE GEL 1% *LACTOBACILLUS - PACKET**

Appendix F9 117 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACETAMINOPHEN TAB 500 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% PSEUDOEPHEDRINE HCL TAB 60 MG *VAPORIZERS*** *RESPIRATORY THERAPY SUPPLIES - MISC** *ADHESIVE BANDAGES - PADS*** NONOXYNOL-9 FILM 28% HYDROCORTISONE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS CAP** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *LANCETS*** *MULTIPLE VITAMINS W/ IRON TAB** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-125 UNIT LEVOTHYROXINE SODIUM TAB 88 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT) Y *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** *SPECIALITY VITAMIN PRODUCT CAP** ETODOLAC TAB ER 24HR 600 MG LIDOCAINE PATCH 4% *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS PACK** FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON) LIDOCAINE PATCH 4% CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT BISMUTH SUBSALICYLATE SUSP 262 MG/15ML FOSINOPRIL SODIUM TAB 40 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ACETAMINOPHEN CHEW TAB 80 MG *LANCETS*** POVIDONE-IODINE SOLN 10% SENNA SYRUP 176 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CHEW TAB**

Appendix F9 118 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs FLURBIPROFEN TAB 100 MG HYDROCORTISONE CREAM 1% POLYVINYL ALCOHOL OPHTH SOLN 1.4% CHLORPHENIRAMINE MALEATE TAB ER 12 MG LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG *B-COMPLEX W/ MINERALS LIQ** TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV) Y *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *BIOFLAVONOID PRODUCTS TAB ER** EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000) OFLOXACIN OPHTH SOLN 0.3% INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") LINACLOTIDE CAP 72 MCG METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG SENNOSIDES TAB 8.6 MG *ADHESIVE BANDAGES*** DONEPEZIL HYDROCHLORIDE TAB 5 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG PSEUDOEPHEDRINE HCL TAB 30 MG METHOTREXATE SOLN PF AUTO-INJECTOR 17.5 MG/0.35ML Y ENTACAPONE TAB 200 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN PHENOBARBITAL ELIXIR 20 MG/5ML PENICILLIN V POTASSIUM TAB 500 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 1177 MG (471 MG CA) PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) CONDOMS LATEX LUBRICATED *MULTIPLE VITAMIN TAB** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS PACK** *B-COMPLEX W/ C CAP**

Appendix F9 119 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ASPIRIN TAB 325 MG NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG *ORAL ELECTROLYTE SOLUTION*** CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) *ORAL ELECTROLYTE SOLUTION*** LEVOTHYROXINE SODIUM TAB 125 MCG *LANCETS*** CILOSTAZOL TAB 100 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG *MULTIPLE VITAMIN TAB** POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML DOXYCYCLINE HYCLATE CAP 50 MG *LANCETS*** SENNOSIDES TAB 8.6 MG *MASKS*** *MULTIPLE VITAMINS W/ CALCIUM TAB** INTERFERON BETA-1A SOLN AUTO-INJ 22 MCG/0.5ML (12MU/ML) Y SIMETHICONE CAP 180 MG INTERFERON BETA-1A SOLN AUTO-INJ 22 MCG/0.5ML (12MU/ML) Y *MULTIPLE VITAMINS W/ MINERALS PACK** GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS PACK** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *MULTIPLE VITAMINS W/ MINERALS PACK** *MULTIPLE VITAMINS W/ MINERALS PACK** *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 600 MG ACETAMINOPHEN TAB 500 MG ACETAMINOPHEN TAB 325 MG DIPHENHYDRAMINE HCL TAB 25 MG

Appendix F9 120 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LEVOTHYROXINE SODIUM TAB 100 MCG SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF) *MULTIPLE VITAMINS W/ IRON TAB** ISOTRETINOIN CAP 40 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** GUAIFENESIN SYRUP 100 MG/5ML CONDOMS LATEX LUBRICATED ACETAMINOPHEN CHEW TAB 80 MG PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS TAB** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ABACAVIR SULFATE TAB 300 MG (BASE EQUIV) ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML PROPRANOLOL HCL CAP ER 24HR 80 MG WARFARIN SODIUM TAB 5 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG *SPECIALITY VITAMIN PRODUCT CAP** FLUCONAZOLE TAB 150 MG INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG MELATONIN SL TAB 1 MG SIROLIMUS ORAL SOLN 1 MG/ML CONDOMS NON-LATEX LUBRICATED CONDOMS LATEX LUBRICATED *LACTOBACILLUS CAP** *OMEGA-3 FATTY ACIDS CAP 1200 MG** *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG DILTIAZEM HCL CAP ER 12HR 120 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2")

Appendix F9 121 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CONDOMS LATEX LUBRICATED BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG CONDOMS LATEX LUBRICATED NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG *OMEGA-3 FATTY ACIDS CAP 1000 MG** *VITAMINS A & D CAP*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN LABETALOL HCL TAB 300 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN *LANCETS*** CALCIUM ASCORBATE TAB 500 MG SUMATRIPTAN SUCCINATE TAB 50 MG FERROUS SULFATE TAB 27 MG (ELEMENTAL FE) TAB 100 MG Y DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) HYDROXYPROGESTERONE CAPROATE SOLN AUTO-INJECTOR 275 MG/1.1ML Y MECLIZINE HCL TAB 25 MG RALTEGRAVIR POTASSIUM CHEW TAB 25 MG (BASE EQUIV) ACETAMINOPHEN SUPPOS 120 MG *LANCETS*** OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV) *LANCETS*** MECLIZINE HCL TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB ER** *LANCETS*** BISMUTH SUBSALICYLATE SUSP 262 MG/15ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB ER** ATAZANAVIR SULFATE-COBICISTAT TAB 300-150 MG (BASE EQUIV) CHLORPHENIRAMINE MALEATE TAB 4 MG ASPIRIN TAB 325 MG ASPIRIN TAB DELAYED RELEASE 81 MG

Appendix F9 122 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT CYCLOSPORINE MODIFIED CAP 100 MG LIOTHYRONINE SODIUM TAB 5 MCG LAMIVUDINE TAB 100 MG (HBV) *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML ACETAMINOPHEN LIQUID 167 MG/5ML *ADHESIVE BANDAGES*** CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG FERROUS SULFATE TAB ER 142 MG (45 MG FE EQUIVALENT) SENNOSIDES TAB 25 MG *LANCETS*** *LANCETS*** *B-COMPLEX W/ FOLIC ACID TAB** *LANCETS*** ACETAMINOPHEN SUSP 160 MG/5ML NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG MELATONIN TAB ER 10 MG FERROUS SULFATE DRIED TAB ER 45 MG (FE EQUIVALENT) HYOSCYAMINE SULFATE TAB ER 0.375 MG (0.125 MG IR/0.25 MG ER) INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *LANCETS*** *ORAL ELECTROLYTE SOLUTION*** HYDRALAZINE HCL TAB 50 MG *LANCETS*** SIMVASTATIN TAB 10 MG CETIRIZINE HCL CHEW TAB 10 MG *LANCETS*** METHAZOLAMIDE TAB 50 MG PSEUDOEPHEDRINE HCL TAB 60 MG FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV) Y

Appendix F9 123 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DOCUSATE SODIUM CAP 100 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") OMALIZUMAB FOR INJ 150 MG Y WARFARIN SODIUM TAB 4 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML TOLNAFTATE CREAM 1% METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV) BISACODYL SUPPOS 10 MG NORETHINDRONE TAB 0.35 MG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG Y DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML SIROLIMUS TAB 0.5 MG TEMOZOLOMIDE CAP 20 MG Y ASPIRIN TAB 325 MG NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC) TIMOLOL MALEATE TAB 10 MG *VITAMINS W/ LIPOTROPICS TAB** PANCRELIPASE (LIP-PROT-AMYL) DR CAP 40000-126000-168000 UNIT TRIAMCINOLONE ACETONIDE CREAM 0.1% NEOMYCIN-POLYMYXIN-HC OPHTH SUSP CARBAMIDE PEROXIDE 6.5% OTIC SOLN ETODOLAC CAP 200 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML BISACODYL TAB DELAYED RELEASE 5 MG NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG DIPHENHYDRAMINE HCL TAB 25 MG *LANCETS*** ASPIRIN TAB DELAYED RELEASE 325 MG POTASSIUM BICARBONATE EFFER TAB 25 MEQ *ADHESIVE BANDAGES*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN NAPROXEN SODIUM TAB 220 MG

Appendix F9 124 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MASKS*** *RESPIRATORY THERAPY SUPPLIES - MISC** *RESPIRATORY THERAPY SUPPLIES - MISC** *RESPIRATORY THERAPY SUPPLIES - MISC** *RESPIRATORY THERAPY SUPPLIES - MISC** TAB 60 MG Y *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) CHOLECALCIFEROL TAB 125 MCG (5000 UNIT) BISMUTH SUBSALICYLATE CHEW TAB 262 MG NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML GALANTAMINE HYDROBROMIDE ORAL SOLN 4 MG/ML CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-250 MG ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML Y *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB 29-1 MG*** AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML DIGOXIN TAB 62.5 MCG (0.0625 MG) SENNOSIDES TAB 8.6 MG ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT) Y *ADHESIVE BANDAGES*** *ACETIC ACID VAGINAL SOLUTION** SEVELAMER CARBONATE PACKET 2.4 GM Y THEOPHYLLINE TAB ER 24HR 600 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB** FULVESTRANT INJ 250 MG/5ML Y CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT) SIPONIMOD FUMARATE TAB 0.25 MG (BASE EQUIV) Y HYDROCORTISONE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS TAB** GLYCOPYRROLATE ORAL SOLN 1 MG/5ML DOCUSATE SODIUM CAP 100 MG

Appendix F9 125 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *RESPIRATORY THERAPY SUPPLIES - MISC** *LANCETS*** *ADHESIVE BANDAGES - PADS*** *LACTOBACILLUS TAB** CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) ASPIRIN TAB DELAYED RELEASE 325 MG *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** HCL TAB 5 MG BACITRACIN OINT 500 UNIT/GM OLIVE OIL CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG MICONAZOLE NITRATE VAGINAL SUPP 1200 MG & 2% CREAM KIT DEXAMETHASONE TAB 1.5 MG ACETAMINOPHEN TAB 500 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML MARAVIROC TAB 75 MG *RESPIRATORY THERAPY SUPPLIES - MISC** MICONAZOLE NITRATE POWDER 2% *RESPIRATORY THERAPY SUPPLIES - MISC** *SPECIALITY VITAMIN PRODUCT EFFER TAB** FAMOTIDINE FOR SUSP 40 MG/5ML *OMEGA-3 FATTY ACIDS - ORAL LIQUID** MELATONIN TAB ER 3 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *OMEGA-3 FATTY ACIDS CAP 1200 MG** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMIN TAB** *OMEGA-3 FATTY ACIDS - ORAL LIQUID**

Appendix F9 126 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VITAMINS W/ LIPOTROPICS CAP** INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG GUAIFENESIN TAB 200 MG *RESPIRATORY THERAPY SUPPLIES - MISC** DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG *LACTOBACILLUS CAP** ZOLMITRIPTAN TAB 2.5 MG Y FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE) *SPECIALITY VITAMIN PRODUCT TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML IBUPROFEN TAB 200 MG *B-COMPLEX W/ MINERALS TAB** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *ADHESIVE BANDAGES*** BISMUTH SUBSALICYLATE SUSP 525 MG/15ML *LACTOBACILLUS CAP DELAYED RELEASE** CAPTOPRIL TAB 50 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-125 UNIT FAMCICLOVIR TAB 250 MG MICONAZOLE NITRATE CREAM 2% VENETOCLAX TAB 50 MG Y *LANCETS*** *ALCOHOL SWABS*** VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG *PEDIATRIC VITAMIN CHEW TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-200 UNIT MEGESTROL ACETATE TAB 20 MG HYDROCORTISONE OINT 1% DIPHENHYDRAMINE HCL CAP 25 MG TAMSULOSIN HCL CAP 0.4 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG

Appendix F9 127 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML SENNOSIDES TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DIPHENHYDRAMINE HCL CAP 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG) SOTALOL HCL TAB 160 MG MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) Y *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB** FAMOTIDINE TAB 10 MG *VAPORIZERS*** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR *VITAMINS W/ LIPOTROPICS TAB** HYDROCORTISONE TAB 20 MG EVOLOCUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** DOXYCYCLINE HYCLATE TAB 100 MG LINEZOLID IV SOLN 200 MG/100ML (2 MG/ML) Y ASPIRIN TAB DELAYED RELEASE 325 MG DIPHENHYDRAMINE HCL TAB 25 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT SIMETHICONE SUSP 40 MG/0.6ML TORSEMIDE TAB 5 MG DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG ROPINIROLE HYDROCHLORIDE TAB 4 MG *BREWERS YEAST TAB*** ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT) METHOTREXATE SOLN PF AUTO-INJECTOR 10 MG/0.2ML Y *VITAMINS W/ LIPOTROPICS CAP** *ORAL ELECTROLYTE SOLUTION*** CHOLECALCIFEROL TAB 25 MCG (1000 UNIT)

Appendix F9 128 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VITAMINS ACE & ZN CAP*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** LEVOTHYROXINE SODIUM TAB 125 MCG *LANCETS*** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 120-1200 MG TRIFLURIDINE OPHTH SOLN 1% *VAPORIZERS*** FELODIPINE TAB ER 24HR 10 MG SIMETHICONE CHEW TAB 80 MG *ADHESIVE BANDAGES*** PEGINTERFERON ALFA-2A INJ 180 MCG/0.5ML Y *ADHESIVE BANDAGES*** CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) DIPHENHYDRAMINE HCL (SLEEP) TAB 50 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 325 MG *LANCETS*** TRAMETINIB DIMETHYL TAB 2 MG (BASE EQUIVALENT) Y DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML ACETAMINOPHEN LIQUID 160 MG/5ML DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG NITROGLYCERIN TD PATCH 24HR 0.8 MG/HR *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML ISOTRETINOIN CAP 10 MG Y BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT)

Appendix F9 129 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ARTIFICIAL TEAR OPHTH SOLUTION*** BACITRACIN ZINC OINT 500 UNIT/GM *BREWERS YEAST TAB*** *VITAMIN D & K TAB*** NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG *LANCETS*** *VAPORIZERS*** *PEDIATRIC MULTIPLE VITAMINS W/ IRON LIQ 10 MG/5ML** *MULTIPLE VITAMINS W/ MINERALS CAP** POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ ISOTRETINOIN CAP 20 MG Y MOMETASONE FUROATE OINT 0.1% *LANCETS*** ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT) FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) TESTOSTERONE TD GEL 25 MG/2.5GM (1%) Y CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) *LACTOBACILLUS TAB** CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) *OMEGA-3 FATTY ACIDS CAP 1000 MG** FERROUS SULFATE DRIED TAB ER 160 MG (50 MG FE EQUIVALENT) CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") CASTOR OIL VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG Y LEVOTHYROXINE SODIUM TAB 300 MCG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS CAP** BISACODYL TAB DELAYED RELEASE 5 MG IBUPROFEN TAB 200 MG *PEDIATRIC MULTIPLE VITAMIN LIQ** RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ) Y GUAIFENESIN TAB ER 12HR 600 MG

Appendix F9 130 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACETAMINOPHEN TAB 500 MG TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG ALLOPURINOL TAB 100 MG HYDROCORTISONE CREAM 1% DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 25 MCG/0.42ML Y *MULTIPLE VITAMINS W/ MINERALS PACK** *LACTOBACILLUS RHAMNOSUS (GG) CAP** INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 500 UNIT/ML PSEUDOEPHEDRINE HCL TAB 30 MG *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** CLARITHROMYCIN TAB ER 24HR 500 MG DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** LACTIC ACID (AMMONIUM LACTATE) CREAM 12% LACTIC ACID (AMMONIUM LACTATE) CREAM 12% LEVOTHYROXINE SODIUM TAB 137 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** ISOTRETINOIN CAP 20 MG Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") DORNASE ALFA INHAL SOLN 1 MG/ML Y IBUPROFEN TAB 200 MG *LANCETS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) *LANCETS*** SIMVASTATIN TAB 80 MG *B-COMPLEX W/ C TAB** SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG

Appendix F9 131 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) LOPERAMIDE HCL CAP 2 MG ETODOLAC TAB ER 24HR 500 MG PHENOBARBITAL TAB 97.2 MG *LACTOBACILLUS - PACKET** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *LANCETS*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ACYCLOVIR CAP 200 MG *LANCETS*** FAMOTIDINE TAB 20 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") DOCUSATE SODIUM CAP 100 MG *ADHESIVE BANDAGES*** OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML) Y *ADHESIVE BANDAGES*** PENICILLIN V POTASSIUM TAB 250 MG TOLVAPTAN TAB 15 MG Y CYCLOSPORINE MODIFIED CAP 25 MG *ADHESIVE BANDAGES*** CHLORPHENIRAMINE MALEATE TAB 4 MG *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** BETAXOLOL HCL OPHTH SOLN 0.5% APREPITANT CAPSULE THERAPY PACK 80 & 125 MG Y *LANCETS*** *LANCETS*** *VITAMINS A & D CAP*** *LANCETS*** *LANCETS*** GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML *LANCETS*** LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG

Appendix F9 132 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs HYDROCORTISONE BUTYRATE CREAM 0.1% HYPROMELLOSE OPHTH SOLN 0.3% VERAPAMIL HCL TAB ER 180 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT SIMETHICONE ORAL STRIP 40 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** VEMURAFENIB TAB 240 MG Y PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG POLYVINYL ALCOHOL OPHTH SOLN 1.4% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML CILOSTAZOL TAB 50 MG LINACLOTIDE CAP 290 MCG PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG *RESPIRATORY THERAPY SUPPLIES - MISC** DONEPEZIL HYDROCHLORIDE TAB 10 MG BISACODYL TAB DELAYED RELEASE 5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG LEUPROLIDE ACETATE (6 MONTH) FOR SUBCUTANEOUS INJ KIT 45 MG Y MEDROXYPROGESTERONE ACETATE TAB 10 MG SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF) *ADHESIVE BANDAGES*** *LANCETS*** ERTUGLIFLOZIN-METFORMIN HCL TAB 2.5-500 MG Y FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) LEVOTHYROXINE SODIUM TAB 112 MCG PROPRANOLOL HCL CAP ER 24HR 60 MG SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG ACETAMINOPHEN CHEW TAB 160 MG

Appendix F9 133 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** FOSINOPRIL SODIUM TAB 20 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG CINACALCET HCL TAB 30 MG (BASE EQUIV) Y *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT ACETAMINOPHEN CHEW TAB 160 MG *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG *BACITRACIN-POLYMYXIN B OINT*** BISMUTH SUBSALICYLATE TAB 262 MG *ADHESIVE BANDAGES*** LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** MELATONIN TABLET DISINTEGRATING 10 MG FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE) *SPECIALITY VITAMIN PRODUCT TAB** LABETALOL HCL TAB 200 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** FERROUS SULFATE ELIXIR 220 MG/5ML (44 MG/5ML ELEMENTAL FE) SUMATRIPTAN SUCCINATE TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-125 UNIT MICONAZOLE NITRATE OINTMENT 2% PERMETHRIN AEROSOL 0.5% CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA)

Appendix F9 134 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG *OMEGA-3 FATTY ACIDS CAP 1200 MG** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *OMEGA-3 FATTY ACIDS CAP 1000 MG** *MULTIPLE VITAMINS W/ MINERALS TAB** PROMETHAZINE HCL SUPPOS 12.5 MG LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) *MULTIPLE VITAMINS W/ MINERALS TAB** AZITHROMYCIN TAB 500 MG GUAIFENESIN SYRUP 100 MG/5ML FERROUS GLUCONATE TAB 240 MG (27 MG ELEMENTAL FE) *ADHESIVE BANDAGES*** *MULTIPLE VITAMIN TAB** CETIRIZINE HCL TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE SUSP 508-475 MG/10ML OMEPRAZOLE CAP DELAYED RELEASE 10 MG *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** LEVOTHYROXINE SODIUM TAB 112 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** ELVITEGRAV-COBIC-EMTRICITAB-TENOFOVDF TAB 150-150-200-300 MG *MULTIPLE VITAMINS W/ IRON TAB** INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16" *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CAPSAICIN CREAM 0.1% *ORAL ELECTROLYTE SOLUTION*** SIMETHICONE CHEW TAB 125 MG

Appendix F9 135 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES - PADS*** *ADHESIVE BANDAGES*** FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** LEVOTHYROXINE SODIUM TAB 25 MCG SELENIUM SULFIDE LOTION 2.5% MILNACIPRAN HCL TAB 12.5 MG (5) & 25 MG (8) & 50 MG (42) PAK Y SIMETHICONE CAP 125 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *OMEGA-3 FATTY ACIDS CAP 1000 MG** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG *CONDOMS - MALE*** *MULTIPLE VITAMINS W/ MINERALS TAB** AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML LANSOPRAZOLE CAP DELAYED RELEASE 15 MG BISMUTH SUBSALICYLATE SUSP 525 MG/15ML *B-COMPLEX VITAMIN ELIXIR** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** CALCIUM TAB 600 MG SENNOSIDES TAB 17.2 MG OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV) CALCIUM CARBONATE-VITAMIN D TAB 500 MG-125 UNIT WARFARIN SODIUM TAB 3 MG SEVELAMER CARBONATE PACKET 0.8 GM Y ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *SPECIALITY VITAMIN PRODUCT TAB**

Appendix F9 136 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS CAP** *LACTOBACILLUS REUTERI CHEW TAB** WARFARIN SODIUM TAB 1 MG PROMETHAZINE HCL TAB 50 MG LEVOFLOXACIN TAB 750 MG *B-COMPLEX W/ C & FOLIC ACID TAB*** CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) GUAIFENESIN LIQUID 100 MG/5ML SODIUM CHLORIDE SOLN NEBU 10% *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV) BISMUTH SUBSALICYLATE CHEW TAB 262 MG CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% *ADHESIVE BANDAGES*** ALLOPURINOL TAB 300 MG POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ BISACODYL SUPPOS 10 MG ACETAMINOPHEN SUSP 160 MG/5ML MEMANTINE HCL ORAL SOLUTION 2 MG/ML *LACTOBACILLUS TAB** *CONDOMS - MALE*** CETIRIZINE HCL CAP 10 MG *MULTIPLE VITAMIN TAB** CLONIDINE TD PATCH WEEKLY 0.2 MG/24HR PROMETHAZINE HCL SUPPOS 25 MG OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV) ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT) *MULTIPLE VITAMINS W/ MINERALS TAB** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** LORATADINE TAB 10 MG SALINE NASAL AEROSOL SOLN 0.9%

Appendix F9 137 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs HYDROCORTISONE OINT 1% DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG DOXYCYCLINE HYCLATE TAB 20 MG ROPINIROLE HYDROCHLORIDE TAB 1 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *SPECIALITY VITAMIN PRODUCT CAP** LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG *SPECIALITY VITAMIN PRODUCT CAP** SIMETHICONE CHEW TAB 80 MG *SPECIALITY VITAMIN PRODUCT CAP** LANSOPRAZOLE CAP DELAYED RELEASE 15 MG DANAZOL CAP 200 MG CLARITHROMYCIN TAB 500 MG CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE CONDOMS LATEX LUBRICATED ENOXAPARIN SODIUM INJ 120 MG/0.8ML CONDOMS LATEX LUBRICATED LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT) GUAIFENESIN LIQUID 100 MG/5ML LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG TOFACITINIB CITRATE TAB 10 MG (BASE EQUIVALENT) Y *MULTIPLE VITAMINS W/ MINERALS TAB** NORETHINDRONE ACETATE TAB 5 MG AMOXICILLIN & K CLAVULANATE TAB 500-125 MG LEVONORGESTREL TAB 1.5 MG LIDOCAINE PATCH 4% CONDOMS LATEX LUBRICATED EMTRICITABINE-RILPIVIRINE-TENOFOVIR AF TAB 200-25-25 MG *B-COMPLEX W/ C-BIOTIN-FE & FOLIC ACID TAB 29-0.8 MG*** HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG Y *SPECIALITY VITAMIN PRODUCT TAB** *CONDOMS - MALE***

Appendix F9 138 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MESALAMINE CAP ER 500 MG Y PYRIDOXINE HCL TAB 50 MG *B-COMPLEX W/ C & FOLIC ACID TAB*** CONDOMS LATEX LUBRICATED INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") DIPHENOXYLATE W/ ATROPINE LIQ 2.5-0.025 MG/5ML *DIAPER RASH PRODUCTS - OINTMENT** *OMEGA-3 FATTY ACIDS CAP 1000 MG** ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV) DIPHENHYDRAMINE HCL TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05% *MULTIPLE VITAMINS W/ MINERALS TAB** DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG MARAVIROC TAB 150 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML ASPIRIN TAB 325 MG CONDOMS LATEX LUBRICATED *ADHESIVE BANDAGES - PADS*** TEMOZOLOMIDE CAP 100 MG Y ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-100 MG DARBEPOETIN ALFA SOLN INJ 100 MCG/ML Y LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE) Y *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG SIMETHICONE CHEW TAB 125 MG SOTALOL HCL TAB 120 MG ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TAB 300-150-300 MG

Appendix F9 139 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs WARFARIN SODIUM TAB 4 MG *LACTOBACILLUS CAP** NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES - PADS*** *LANCETS*** PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG ENTECAVIR TAB 0.5 MG *LANCETS*** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") SULFASALAZINE TAB DELAYED RELEASE 500 MG ERYTHROMYCIN TAB 250 MG DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG WARFARIN SODIUM TAB 2.5 MG CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML) CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) CONDOMS LATEX NON-LUBRICATED ACETAMINOPHEN TAB 500 MG TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG AMOXICILLIN (TRIHYDRATE) CHEW TAB 250 MG DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG HYDROCORTISONE VALERATE CREAM 0.2% NATEGLINIDE TAB 120 MG *LANCETS*** CEFADROXIL FOR SUSP 500 MG/5ML CONDOMS LATEX LUBRICATED SOTALOL HCL TAB 120 MG DOCUSATE SODIUM SYRUP 60 MG/15ML *BIOFLAVONOID PRODUCTS CAP** INSULIN NPH (HUMAN) (ISOPHANE) SUSP PEN-INJECTOR 100 UNIT/ML CETIRIZINE HCL TAB 10 MG

Appendix F9 140 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LACTOBACILLUS CAP** *MULTIPLE VITAMINS W/ MINERALS PACK** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG METHYLPREDNISOLONE TAB 16 MG LEVOTHYROXINE SODIUM TAB 125 MCG COLCHICINE TAB 0.6 MG BENZOYL PEROXIDE CREAM 10% HYDROCORTISONE LOTION 1% *ALCOHOL SWABS*** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *LANCETS*** BENZOYL PEROXIDE CREAM 10% *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** PROPRANOLOL HCL TAB 80 MG CALCIUM CARBONATE CHEW TAB 1250 MG (500 MG ELEMENTAL CA) HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML Y *ADHESIVE BANDAGES*** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 120-1200 MG INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") CHLORPHENIRAMINE MALEATE TAB 4 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DRONABINOL CAP 2.5 MG ASPIRIN TAB 500 MG SENNOSIDES CAP 8.6 MG DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML PANCRELIPASE (LIP-PROT-AMYL) DR CAP 15000-47000-63000 UNIT NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** CLOTRIMAZOLE TROCHE 10 MG ACETAMINOPHEN SUPPOS 650 MG PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 120-1200 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 141 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs SENNOSIDES TAB 25 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG PARICALCITOL CAP 2 MCG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *ADHESIVE BANDAGES*** ACETAMINOPHEN TAB 500 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") *COD LIVER OIL*** *ADHESIVE BANDAGES*** *ALCOHOL SWABS*** *ADHESIVE BANDAGES*** APIXABAN TAB 5 MG *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** CALCIUM CARBONATE-VITAMIN D TAB 250 MG-125 UNIT AMOXICILLIN (TRIHYDRATE) TAB 500 MG *LANCETS*** NITROGLYCERIN SL TAB 0.3 MG *LACTOBACILLUS - WAFER** CALCIUM CARBONATE-CHOLECALCIFEROL CHEW TAB 500 MG-600 UNIT ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML DORAVIRINE TAB 100 MG ISOTRETINOIN CAP 30 MG Y CONDOMS LATEX LUBRICATED *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** METRONIDAZOLE GEL 1% Y *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** LORATADINE SYRUP 5 MG/5ML *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** CONDOMS LATEX LUBRICATED ECULIZUMAB IV SOLN 300 MG/30ML (10 MG/ML) (FOR INFUSION) Y SENNOSIDES TAB 15 MG CALCIUM TAB 500 MG PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML

Appendix F9 142 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 11 MG/ML** NIACIN TAB ER 750 MG (ANTIHYPERLIPIDEMIC) LAMIVUDINE TAB 150 MG LEVOTHYROXINE SODIUM TAB 200 MCG GALANTAMINE HYDROBROMIDE TAB 8 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 70 MG/ML Y HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML *VITAMINS W/ LIPOTROPICS TAB** INTERFERON ALFA-2B FOR INJ 50000000 UNIT Y BENZOYL PEROXIDE GEL 10% MACITENTAN TAB 10 MG Y SENNOSIDES TAB 8.6 MG *BIOFLAVONOID PRODUCTS TAB** KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) *LANCETS*** CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% *MULTIPLE VITAMINS W/ MINERALS TAB** KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *VITAMINS A & D W/ C CHEW TAB*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** LORATADINE TAB 10 MG SENNOSIDES TAB 15 MG INTERFERON ALFA-2B FOR INJ 18000000 UNIT Y

Appendix F9 143 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VITAMINS W/ LIPOTROPICS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT) Y GLECAPREVIR-PIBRENTASVIR TAB 100-40 MG Y BISMUTH SUBSALICYLATE TAB 262 MG SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF) *RESPIRATORY THERAPY SUPPLIES - MISC** NORETHINDRONE TAB 0.35 MG LEVOTHYROXINE SODIUM TAB 175 MCG CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLN 0.5% PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG *SPECIALITY VITAMIN PRODUCT TAB** PSEUDOEPHEDRINE W/ COD-GG SOLN 30-10-100 MG/5ML BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1% *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** HYDROCORTISONE CREAM 1% *ARTIFICIAL TEAR OPHTH SOLUTION*** ORAL GRANULES PACKET 10 GM BACITRACIN ZINC OINT 500 UNIT/GM *BIOFLAVONOID PRODUCTS CAP** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG BISACODYL TAB DELAYED RELEASE 5 MG PROPAFENONE HCL TAB 225 MG CONDOMS LATEX LUBRICATED CONDOMS LATEX LUBRICATED HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG Y *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS CAP** *LACTOBACILLUS CAP** *RESPIRATORY THERAPY SUPPLIES - MISC** FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 300 MCG/0.5ML Y

Appendix F9 144 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACARBOSE TAB 25 MG MELATONIN SL TAB 10 MG LENALIDOMIDE CAP 25 MG Y ASPIRIN CHEW TAB 81 MG ACETAMINOPHEN DISINTEGRATING TAB 160 MG *B-COMPLEX VITAMIN TAB** ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML) SIMVASTATIN TAB 40 MG *ALCOHOL SWABS*** ISOTRETINOIN CAP 10 MG Y FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG WARFARIN SODIUM TAB 6 MG PERMETHRIN AEROSOL 0.5% ACETAMINOPHEN TAB 325 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT) Y BACITRACIN ZINC OINT 500 UNIT/GM *ORAL ELECTROLYTE SOLUTION*** *MULTIPLE VITAMINS W/ MINERALS TAB** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR *PRENAT W/O A W/FE FUM-FE CBN-DSS-FA-DHA CAP 27-1-260 MG*** *MULTIPLE VITAMINS W/ MINERALS TAB** BRIMONIDINE TARTRATE OPHTH SOLN 0.2% MELATONIN CAP 10 MG CLOTRIMAZOLE CREAM 1% *LACTOBACILLUS TAB** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *OMEGA-3 FATTY ACIDS CAP 1000 MG** TREPROSTINIL DIOLAMINE TAB ER 1 MG (BASE EQUIV) Y METHYLPREDNISOLONE TAB 32 MG *MULTIPLE VITAMINS W/ MINERALS TAB** POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ

Appendix F9 145 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV) RIVASTIGMINE TD PATCH 24HR 4.6 MG/24HR Y IBUPROFEN CHEW TAB 100 MG METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV) FEXOFENADINE HCL TAB 180 MG GUANFACINE HCL TAB 1 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** RALTEGRAVIR POTASSIUM PACKET FOR SUSP 100 MG (BASE EQUIV) INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64" SIMETHICONE CAP 125 MG ACETAMINOPHEN DISINTEGRATING TAB 160 MG *VAPORIZERS*** LABETALOL HCL TAB 100 MG CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) LACTIC ACID (AMMONIUM LACTATE) LOTION 12% GUAIFENESIN TAB ER 12HR 1200 MG *MULTIPLE VITAMINS W/ MINERALS PACK** NYSTATIN SUSP 100000 UNIT/ML HYOSCYAMINE SULFATE TAB DISINT 0.125 MG CALCIUM CITRATE MALATE-CHOLECALCIFEROL TAB 250 MG-100 UNIT *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** PROMETHAZINE HCL SUPPOS 25 MG CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) ACETAMINOPHEN TAB 500 MG CALCIUM CARBONATE CHEW TAB 1250 MG (500 MG ELEMENTAL CA) *BACITRACIN-POLYMYXIN B OINT*** FLUDROCORTISONE ACETATE TAB 0.1 MG THEOPHYLLINE CAP ER 24HR 300 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 146 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** ACETAMINOPHEN TAB 325 MG CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) LENVATINIB CAP THER PACK 10 MG & 2 X 4 MG (18 MG DAILY DOSE) Y POLYETHYLENE GLYCOL 3350 ORAL PACKET 17 GM ERYTHROMYCIN TAB 500 MG POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ CONDOMS LATEX LUBRICATED CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG MESALAMINE CAP ER 24HR 0.375 GM PYRIDOXINE HCL TAB 50 MG BROMPHENIRAMINE & PSEUDOEPHEDRINE ELIXIR 1-15 MG/5ML FOLIC ACID TAB 800 MCG CEFUROXIME AXETIL TAB 250 MG LIOTHYRONINE SODIUM TAB 50 MCG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT ALOGLIPTIN BENZOATE TAB 6.25 MG (BASE EQUIV) *ADHESIVE BANDAGES*** *LANCETS*** CALCIUM ASCORBATE TAB 500 MG FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT *CONDOMS - MALE*** *LANCETS*** *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** *MULTIPLE VITAMINS W/ MINERALS PACK** CHLORTHALIDONE TAB 25 MG FEXOFENADINE HCL ORALLY DISINTEGRATING TAB 30 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT MEGESTROL ACETATE SUSP 40 MG/ML *ACETIC ACID VAGINAL SOLUTION** *ADHESIVE BANDAGES*** FEXOFENADINE HCL ORALLY DISINTEGRATING TAB 30 MG BROMPHENIRAMINE & PSEUDOEPHEDRINE ELIXIR 1-15 MG/5ML

Appendix F9 147 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ADHESIVE BANDAGES*** FERROUS FUMARATE TAB 324 MG (106 MG ELEMENTAL FE) *BIOFLAVONOID PRODUCTS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** DOCUSATE SODIUM SYRUP 60 MG/15ML *LANCETS*** TETRACYCLINE HCL CAP 500 MG ALCLOMETASONE DIPROPIONATE CREAM 0.05% *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** IVACAFTOR PACKET 25 MG Y *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG *LANCETS*** DANAZOL CAP 50 MG CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML) SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 400 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *MULTIPLE VITAMIN TAB** SUMATRIPTAN NASAL SPRAY 20 MG/ACT *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP LEVONORGESTREL TAB 1.5 MG *LANCETS*** ACETAMINOPHEN SUSP 160 MG/5ML *LANCETS*** TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1% BISOPROLOL FUMARATE TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 148 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/ FOLIC ACID TAB** *SPECIALITY VITAMIN PRODUCT CAP** SENNOSIDES TAB 8.6 MG FLUCONAZOLE TAB 50 MG FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-1 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML FEXOFENADINE HCL TAB 180 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS LIQUID** *LANCETS*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** CALCIUM-MAGNESIUM-ZINC TAB 333-133-8.3 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ) Y *B-COMPLEX VITAMIN TAB ER** *SPECIALITY VITAMIN PRODUCT TAB** SIMETHICONE CAP 180 MG PALBOCICLIB CAP 125 MG Y CHOLECALCIFEROL TAB 10 MCG (400 UNIT) ALFUZOSIN HCL TAB ER 24HR 10 MG IBUPROFEN TAB 800 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML LAROTRECTINIB SULFATE CAP 25 MG (BASE EQUIVALENT) Y RITONAVIR ORAL SOLN 80 MG/ML *MULTIPLE VITAMINS W/ MINERALS TAB** FLUOCINONIDE OINT 0.05% PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG

Appendix F9 149 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG *LACTOBACILLUS - WAFER** IBUPROFEN CAP 200 MG FLUTICASONE-SALMETEROL AER POWDER BA 232-14 MCG/ACT DOCUSATE SODIUM CAP 250 MG ACETAMINOPHEN CAP 500 MG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG *LANCETS*** *ADHESIVE BANDAGES*** OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML) Y CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG CALCIUM W/ MAGNESIUM TAB 500-250 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *ORAL ELECTROLYTE SOLUTION*** CALCIUM-MAG-VIT C-VIT D CAP 185 MG-28 MG-2.5 MG-200 UNIT DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *ORAL ELECTROLYTE SOLUTION*** *ADHESIVE BANDAGES*** ACETAMINOPHEN CHEW TAB 80 MG *ORAL ELECTROLYTE SOLUTION*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *ORAL ELECTROLYTE SOLUTION*** *ORAL ELECTROLYTE SOLUTION*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") DAPSONE TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ALBUTEROL SULFATE TAB ER 12HR 4 MG ACETAMINOPHEN TAB 325 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** MEMANTINE HCL TAB 5 MG PANCRELIPASE (LIP-PROT-AMYL) TAB 20880-78300-78300 UNIT

Appendix F9 150 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV) NATEGLINIDE TAB 60 MG POVIDONE-IODINE SOLN 10% GUAIFENESIN TAB 400 MG LEVOFLOXACIN TAB 250 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** CHLORHEXIDINE GLUCONATE SOLN 4% FENOFIBRATE TAB 54 MG CONDOMS LATEX LUBRICATED MICONAZOLE NITRATE VAGINAL SUPPOS 100 MG *CONDOMS - MALE*** *B-COMPLEX W/ IRON TAB** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML Y PROMETHAZINE HCL TAB 25 MG CLONIDINE TD PATCH WEEKLY 0.1 MG/24HR *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** CONDOMS LATEX LUBRICATED *MASKS*** METHOTREXATE SODIUM TAB 15 MG (BASE EQUIV) APIXABAN TAB 2.5 MG POLYVINYL ALCOHOL-POVIDONE OPHTH SOLN 5-6 MG/ML (0.5-0.6%) DILTIAZEM HCL COATED BEADS TAB ER 24HR 420 MG POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP PSEUDOEPHEDRINE HCL TAB ER 24HR 240 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG ASPIRIN TAB DELAYED RELEASE 81 MG *ADHESIVE BANDAGES*** SENNOSIDES TAB 8.6 MG DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML ASPIRIN TAB DELAYED RELEASE 81 MG CONDOMS LATEX LUBRICATED

Appendix F9 151 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML) *RESPIRATORY THERAPY SUPPLIES - MISC** NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG ASPIRIN TAB DELAYED RELEASE 325 MG DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML SOTALOL HCL TAB 160 MG *MASKS*** FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV) IBUPROFEN SUSP 100 MG/5ML *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPECIALITY VITAMIN PRODUCT CAP** *B-COMPLEX W/ C & FOLIC ACID TAB*** CHLORHEXIDINE GLUCONATE SOLN 0.12% CALCIUM-CHOLECALCIFEROL TAB 500 MG-200 UNIT CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) PANCRELIPASE (LIP-PROT-AMYL) DR CAP 20000-63000-84000 UNIT CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG WARFARIN SODIUM TAB 3 MG LOPERAMIDE HCL TAB 2 MG *BIOFLAVONOID PRODUCTS TAB** *ADHESIVE BANDAGES*** CALCIUM CARBONATE-ERGOCALCIFEROL TAB 500MG-200 UNIT MICONAZOLE NITRATE CREAM 2% *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** MARAVIROC ORAL SOLN 20 MG/ML CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT CALCITRIOL ORAL SOLN 1 MCG/ML RIFABUTIN CAP 150 MG CEFADROXIL FOR SUSP 250 MG/5ML MELATONIN TAB 5 MG DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML POLYVINYL ALCOHOL-POVIDONE OPHTH SOLN 5-6 MG/ML (0.5-0.6%) SOTALOL HCL TAB 80 MG

Appendix F9 152 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INSULIN REGULAR (HUMAN) SOLN PEN-INJECTOR 100 UNIT/ML BENZOYL PEROXIDE LIQ 4% *RESPIRATORY THERAPY SUPPLIES - MISC** AFATINIB DIMALEATE TAB 40 MG (BASE EQUIVALENT) Y PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV) TOLNAFTATE CREAM 1% POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% PROMETHAZINE HCL SUPPOS 12.5 MG MARAVIROC TAB 300 MG LORATADINE CHEW TAB 5 MG SALINE NASAL SPRAY 0.65% *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) GUAIFENESIN TAB ER 12HR 600 MG CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV) ACETAMINOPHEN TAB 325 MG CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 10-100 MG DARBEPOETIN ALFA SOLN INJ 200 MCG/ML Y LEVOTHYROXINE SODIUM TAB 300 MCG AMOXICILLIN & K CLAVULANATE TAB 250-125 MG *ADHESIVE BANDAGES*** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** DIPHENHYDRAMINE HCL CAP 25 MG CLOTRIMAZOLE SOLN 1% *ADHESIVE BANDAGES*** *B-COMPLEX W/ C-ZN & FOLIC ACID TAB 0.8 MG*** PERMETHRIN AEROSOL 0.5% *ADHESIVE BANDAGES*** FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-0.5 MG GALANTAMINE HYDROBROMIDE CAP ER 24HR 24 MG ACETAZOLAMIDE CAP ER 12HR 500 MG SOTALOL HCL (AFIB/AFL) TAB 160 MG CHOLECALCIFEROL TAB 125 MCG (5000 UNIT)

Appendix F9 153 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs PARICALCITOL CAP 4 MCG PARICALCITOL CAP 1 MCG CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) TAB 1 GM ISOSORBIDE MONONITRATE TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES TAB 8.6 MG NORETHINDRONE TAB 0.35 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** METHYLPREDNISOLONE TAB 8 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** LUMACAFTOR-IVACAFTOR GRANULES PACKET 100-125 MG Y BETAMETHASONE DIPROPIONATE OINT 0.05% INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML LENALIDOMIDE CAP 10 MG Y ISOTRETINOIN CAP 40 MG Y *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML LEVOTHYROXINE SODIUM TAB 137 MCG PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG *ORAL ELECTROLYTE SOLUTION*** LEVOCARNITINE CAP 250 MG FLUTICASONE PROPIONATE CREAM 0.05% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML NITROGLYCERIN SL TAB 0.4 MG *MULTIPLE VITAMINS W/ MINERALS LIQUID** ISOTRETINOIN CAP 20 MG Y DEXTRAN 70-HYPROMELLOSE OPHTH SOLN 0.1-0.3%

Appendix F9 154 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LAMIVUDINE TAB 300 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") GALANTAMINE HYDROBROMIDE TAB 4 MG NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC) DRONABINOL CAP 5 MG *LANCETS*** TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT) Y SIROLIMUS TAB 2 MG LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT *VAPORIZERS*** *LANCETS*** LIDOCAINE PATCH 4% ACETAMINOPHEN LIQUID 160 MG/5ML *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG *LANCETS*** CALCIUM CARBONATE-MAG HYDROXIDE CHEW TAB 550-110 MG THIAMINE HCL TAB 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** GRANISETRON HCL TAB 1 MG BENZOYL PEROXIDE LIQ 5.25% *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** *LANCETS*** PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG GUAIFENESIN TAB 400 MG ASPIRIN TAB 325 MG ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR *RESPIRATORY THERAPY SUPPLIES - MISC** *MULTIPLE VITAMINS W/ MINERALS TAB** LEUCOVORIN CALCIUM TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** MICONAZOLE NITRATE CREAM 2%

Appendix F9 155 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NAPROXEN SODIUM TAB 220 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** ENALAPRIL MALEATE TAB 2.5 MG INDAPAMIDE TAB 2.5 MG TOLNAFTATE AEROSOL POW 1% MEGESTROL ACETATE SUSP 40 MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML Y ROPINIROLE HYDROCHLORIDE TAB 2 MG SIMETHICONE CHEW TAB 80 MG BISACODYL SUPPOS 10 MG RITONAVIR TAB 100 MG *SPECIALITY VITAMIN PRODUCT TAB** *ORAL ELECTROLYTE SOLUTION*** DOXYCYCLINE HYCLATE CAP 100 MG MELATONIN TABLET DISINTEGRATING 500 MCG *OMEGA-3 FATTY ACIDS CHEW TAB 113.5 MG** TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT) POVIDONE-IODINE SOLN 7.5% SODIUM FLUORIDE PASTE 1.1% DIPHENHYDRAMINE HCL TAB 25 MG ENALAPRIL MALEATE TAB 5 MG CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% MUPIROCIN OINT 2% *SPECIALITY VITAMIN PRODUCT TAB** DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG MICONAZOLE NITRATE POWDER 2% MICONAZOLE NITRATE POWDER 2% *BIOFLAVONOID PRODUCTS TAB** VANCOMYCIN HCL CAP 125 MG (BASE EQUIVALENT) Y CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT TACROLIMUS CAP 0.5 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *SPECIALITY VITAMIN PRODUCT TAB**

Appendix F9 156 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs IBRUTINIB CAP 140 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** DOCUSATE SODIUM CAP 100 MG TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML) *LACTOBACILLUS TAB** DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG *MULTIPLE VITAMINS W/ MINERALS PACK** SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML CALCIUM CARBONATE-VITAMIN D TAB 500 MG-125 UNIT *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** WARFARIN SODIUM TAB 5 MG IBUPROFEN TAB 200 MG *MULTIPLE VITAMIN TAB** ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** ISOTRETINOIN CAP 30 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** *BIOFLAVONOID PRODUCTS TAB** SODIUM FLUORIDE PASTE 1.1% *B-COMPLEX W/ FOLIC ACID TAB** *VITAMINS C & E CAP*** *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** INTERFERON ALFA-2B FOR INJ 10000000 UNIT Y *VAPORIZERS*** *VAPORIZERS*** *VAPORIZERS*** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA) *ANTISEPTIC PRODUCTS MISC - PADS** ALPHA1-PROTEINASE INHIBITOR (HUMAN) INJ 1000 MG/20ML Y SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)

Appendix F9 157 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VAPORIZERS*** TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT *PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB & DHA CAP 300 MG PACK* FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN TAB 2.5-25-2 MG ASPIRIN CHEW TAB 81 MG *ADHESIVE BANDAGES*** *BIOFLAVONOID PRODUCTS POWDER** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH GEL 1% GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML CETIRIZINE HCL TAB 10 MG *VAPORIZERS*** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT LORATADINE TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LACTOBACILLUS CAP** DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG CAPTOPRIL TAB 25 MG LEVOTHYROXINE SODIUM TAB 175 MCG MORPHINE SULFATE TAB ER 100 MG Y SIMETHICONE CHEW TAB 125 MG AMOXICILLIN & K CLAVULANATE FOR SUSP 125-31.25 MG/5ML *ADHESIVE BANDAGES*** CIMETIDINE TAB 200 MG CONDOMS LATEX LUBRICATED PANOBINOSTAT LACTATE CAP 20 MG (BASE EQUIVALENT) Y ACETAMINOPHEN SUSP 160 MG/5ML DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG SIMETHICONE SUSP 40 MG/0.6ML *LANCETS*** SIMETHICONE CAP 180 MG CONDOMS LATEX LUBRICATED *MULTIPLE VITAMINS W/ MINERALS TAB** DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML

Appendix F9 158 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs OXYCODONE HCL TAB 20 MG Y CASTOR OIL ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACK 2.5 MG *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** GUAIFENESIN TAB 400 MG SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML) PYRIDOXINE HCL TAB 25 MG RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT) Y *OMEGA-3 FATTY ACIDS CAP 1000 MG** COLLAGENASE OINT 250 UNIT/GM Y IBUPROFEN TAB 200 MG TOLNAFTATE SOLN 1% VORINOSTAT CAP 100 MG Y CETIRIZINE HCL TAB 10 MG PREDNISONE ORAL SOLN 5 MG/5ML BISMUTH SUBSALICYLATE SUSP 262 MG/15ML METHOTREXATE SOLN PF AUTO-INJECTOR 22.5 MG/0.45ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** FLUCONAZOLE FOR SUSP 10 MG/ML *ARTIFICIAL TEAR OPHTH OINTMENT*** LEVOTHYROXINE SODIUM TAB 150 MCG *SPECIALITY VITAMIN PRODUCT TAB** CIMETIDINE TAB 200 MG VENETOCLAX TAB 100 MG Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") SOTALOL HCL TAB 240 MG *LANCETS*** ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG SIMETHICONE LIQUID 40 MG/0.6ML *OMEGA-3 FATTY ACIDS CAP 1200 MG**

Appendix F9 159 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs AXITINIB TAB 5 MG Y *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** IBUPROFEN TAB 600 MG *SPECIALITY VITAMIN PRODUCT CAP** COLESTIPOL HCL TAB 1 GM POTASSIUM CHLORIDE CAP ER 10 MEQ HYDROCORTISONE LOTION 1% *LACTOBACILLUS CAP** COLLAGENASE OINT 250 UNIT/GM Y QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG LATANOPROST OPHTH SOLN 0.005% HYDRALAZINE HCL TAB 25 MG GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *LACTOBACILLUS CAP** TRIAMCINOLONE ACETONIDE CREAM 0.025% ASPIRIN TAB DELAYED RELEASE 81 MG CHLORPHENIRAMINE MALEATE TAB ER 12 MG IBUPROFEN TAB 200 MG MEDROXYPROGESTERONE ACETATE TAB 5 MG DEXTROMETHORPHAN-GUAIFENESIN GRANULES PACKET 5-100 MG DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML DILTIAZEM HCL TAB 30 MG LIDOCAINE PATCH 5% Y FOLIC ACID TAB 1 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML NIFEDIPINE TAB ER 24HR 90 MG *LANCETS*** INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") ZIDOVUDINE CAP 100 MG ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 100 MG/ML Y CHOLECALCIFEROL CAP 250 MCG (10000 UNIT)

Appendix F9 160 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *LANCETS*** *MULTIPLE VITAMINS W/ CALCIUM TAB** CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-500 UNIT SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) SELEGILINE HCL CAP 5 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") BISOPROLOL FUMARATE TAB 5 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *ORAL ELECTROLYTE SOLUTION*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** CYCLOPHOSPHAMIDE CAP 50 MG *RESPIRATORY THERAPY SUPPLIES - MISC** FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-1 MG DIPHENHYDRAMINE HCL TAB 25 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML PROPAFENONE HCL TAB 150 MG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG *MASKS*** *MULTIPLE VITAMIN LIQUID** IBUPROFEN TAB 200 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS LIQUID** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMIN CAP** DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML ACETAMINOPHEN CHEW TAB 160 MG *RESPIRATORY THERAPY SUPPLIES - MISC** INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2" INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32")

Appendix F9 161 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) MECLIZINE HCL TAB 12.5 MG MECLIZINE HCL CHEW TAB 25 MG ACETAMINOPHEN TAB ER 650 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FERROUS SULFATE TAB 27 MG (ELEMENTAL FE) SUMATRIPTAN SUCCINATE TAB 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ENFUVIRTIDE FOR INJ 90 MG CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) *URINE GLUCOSE-KETONES TEST STRIPS*** LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG SULFASALAZINE TAB 500 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) SIMVASTATIN TAB 20 MG DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG *MULTIPLE VITAMIN TAB** *VITAMINS A & D CAP*** EMTRICITABINE SOLN 10 MG/ML CONDOMS LATEX LUBRICATED *VITAMINS W/ LIPOTROPICS TAB** FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT *MULTIPLE VITAMINS W/ IRON TAB** *SPECIALITY VITAMIN PRODUCT TAB** CARBAMIDE PEROXIDE 6.5% OTIC SOLN DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG *ORAL ELECTROLYTE SOLUTION*** APIXABAN TAB 5 MG BENZOYL PEROXIDE GEL 5% *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** OLIVE OIL

Appendix F9 162 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *OMEGA-3 FATTY ACIDS CAP 435 MG** SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML DIPHENHYDRAMINE HCL (SLEEP) TAB 50 MG HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG Y LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) AMIODARONE HCL TAB 200 MG *LANCETS*** FLUTICASONE PROPIONATE OINT 0.005% LIOTHYRONINE SODIUM TAB 25 MCG FLUCONAZOLE TAB 100 MG *ADHESIVE BANDAGES*** BENZONATATE CAP 200 MG DIPHENHYDRAMINE HCL CAP 25 MG *ADHESIVE BANDAGES*** OXYCODONE HCL CAP 5 MG Y GUAIFENESIN TAB 200 MG DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH GEL 1% TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT *LANCETS*** *RESPIRATORY THERAPY SUPPLIES - MISC** POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ *MULTIPLE VITAMIN TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** ASPIRIN TAB DELAYED RELEASE 81 MG MORPHINE SULFATE TAB ER 30 MG Y PROPYLENE GLYCOL OPHTH SOLN 0.6% *B-COMPLEX VITAMIN TAB** NIZATIDINE CAP 150 MG *VITAMINS W/ LIPOTROPICS TAB ER** *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** AMIODARONE HCL TAB 200 MG

Appendix F9 163 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ACETAMINOPHEN SUSP 160 MG/5ML *ADHESIVE BANDAGES*** *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG IBUPROFEN SUSP 40 MG/ML CALCIUM TAB 600 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG HYDROCORTISONE PERIANAL CREAM 1% *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) ACETAMINOPHEN CHEW TAB 80 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN HYDROXYPROGESTERONE CAPROATE IM IN OIL 250 MG/ML Y CITRATE TAB ER 12HR 100 MG LIDOCAINE PATCH 4% *MULTIPLE VITAMINS W/ MINERALS TAB** TOLNAFTATE AEROSOL POW 1% LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML Y *ADHESIVE BANDAGES*** BUSULFAN TAB 2 MG ACETAMINOPHEN LIQUID 167 MG/5ML CALCIUM CARBONATE-VITAMIN D TAB 250 MG-125 UNIT DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** ETRAVIRINE TAB 25 MG *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS*** LEVOTHYROXINE SODIUM TAB 50 MCG PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 10 MG (BASE EQ) SOTALOL HCL TAB 160 MG

Appendix F9 164 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VITAMINS W/ LIPOTROPICS TAB ER** POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG PEGINTERFERON ALFA-2A INJ 180 MCG/0.5ML Y *MULTIPLE VITAMINS W/ MINERALS TAB ER** PRAVASTATIN SODIUM TAB 20 MG *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** ERTUGLIFLOZIN-METFORMIN HCL TAB 7.5-500 MG Y *RESPIRATORY THERAPY SUPPLIES - MISC** TOLNAFTATE AEROSOL POW 1% HYDROCORTISONE CREAM 1% LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG WARFARIN SODIUM TAB 6 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** *ALCOHOL SWABS*** FLUCONAZOLE FOR SUSP 40 MG/ML DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** CONDOMS LATEX LUBRICATED *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** GUAIFENESIN TAB ER 12HR 1200 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** SENNOSIDES CHEW TAB 10 MG RALTEGRAVIR POTASSIUM TAB 600 MG (BASE EQUIV) CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG CICLOPIROX GEL 0.77% *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** ACETAMINOPHEN TAB ER 650 MG

Appendix F9 165 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DOCUSATE SODIUM LIQUID 150 MG/15ML QUINAPRIL HCL TAB 20 MG BENZOYL PEROXIDE LIQ 7% *CONDOMS - MALE*** *MULTIPLE VITAMINS W/ MINERALS TAB** ACETAMINOPHEN TAB 325 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *ADHESIVE BANDAGES*** CARBIDOPA & LEVODOPA TAB ER 50-200 MG CLOTRIMAZOLE TROCHE 10 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *SPECIALITY VITAMIN PRODUCT TAB** EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML (1:1000) CINACALCET HCL TAB 90 MG (BASE EQUIV) Y *ADHESIVE BANDAGES*** BISACODYL SUPPOS 10 MG POTASSIUM CHLORIDE TAB ER 10 MEQ *BIOFLAVONOID PRODUCTS TAB** CETIRIZINE HCL CAP 10 MG DEXAMETHASONE TAB 0.75 MG *ADHESIVE BANDAGES*** CHLORPHENIRAMINE MALEATE TAB 4 MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT GALANTAMINE HYDROBROMIDE CAP ER 24HR 16 MG *MULTIPLE VITAMINS W/ MINERALS TAB** NITROGLYCERIN TD PATCH 24HR 0.3 MG/HR SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 50-50 MG CALCIUM CARBONATE-MAG HYDROXIDE SUSP 400-135 MG/5ML TOLNAFTATE AEROSOL POW 1% *ADHESIVE BANDAGES*** MECLIZINE HCL CHEW TAB 25 MG DIPHENHYDRAMINE HCL CAP 50 MG

Appendix F9 166 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs LEVONORGESTREL TAB 1.5 MG MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV) GUAIFENESIN LIQUID 100 MG/5ML *ARTIFICIAL TEAR OPHTH SOLUTION*** MEMANTINE HCL ORAL SOLUTION 2 MG/ML SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT) Y INTERFERON ALFA-2B INJ 6000000 UNIT/ML Y CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-100 UNIT-40 MCG SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG SENNOSIDES CHEW TAB 10 MG AFATINIB DIMALEATE TAB 30 MG (BASE EQUIVALENT) Y HYDROCORTISONE CREAM 1% NITROGLYCERIN SL TAB 0.6 MG PROPYLENE GLYCOL-GLYCERIN OPHTH SOLN 1-0.3% INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") EVOLOCUMAB SUBCUTANEOUS SOLN CARTRIDGE/INFUSOR 420 MG/3.5ML Y DILTIAZEM HCL TAB 120 MG TEMOZOLOMIDE CAP 140 MG Y *MULTIPLE VITAMINS W/ MINERALS CAP** CALCIUM W/ MAGNESIUM TAB 250-125 MG *IRON W/ VITAMIN TAB** CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLN 0.25% DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG*** MORPHINE SULFATE ORAL SOLN 20 MG/5ML Y *LANCETS*** *LANCETS*** LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG *MULTIPLE VITAMINS W/ MINERALS TAB** HCL TAB 60 MG CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML) *IRON W/ VITAMIN LIQ**

Appendix F9 167 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs SENNOSIDES TAB 8.6 MG *VITAMINS W/ LIPOTROPICS TAB** SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF) *RESPIRATORY THERAPY SUPPLIES - MISC** QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-25 MG *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** DIPHENHYDRAMINE HCL CAP 25 MG *RESPIRATORY THERAPY SUPPLIES - MISC** BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT) *VITAMINS W/ LIPOTROPICS TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** *LANCETS*** HYDROCORTISONE PERIANAL CREAM 2.5% *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** HYDROCORTISONE BUTYRATE CREAM 0.1% *MULTIPLE VITAMINS W/ MINERALS TAB ER** *MULTIPLE VITAMINS W/ MINERALS TAB** ESTRADIOL VAGINAL TAB 10 MCG LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG *ADHESIVE BANDAGES*** METOLAZONE TAB 5 MG *MULTIPLE VITAMINS W/ MINERALS TAB ER** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** CARBOXYMETHYLCELL-GLYC-POLYSORB 80 (PF) OPHTH SOL 0.5-1-0.5% LANREOTIDE ACETATE EXTENDED RELEASE INJ 90 MG/0.3ML Y ACETAMINOPHEN TAB ER 650 MG *PEDIATRIC MULTIPLE VITAMIN W/ C SOLN 35 MG/ML** *LANCETS*** ACETAMINOPHEN ELIXIR 160 MG/5ML *RESPIRATORY THERAPY SUPPLIES - MISC** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *ADHESIVE BANDAGES***

Appendix F9 168 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ADHESIVE BANDAGES*** FERROUS SULFATE ELIXIR 220 MG/5ML (44 MG/5ML ELEMENTAL FE) ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2" *MULTIPLE VITAMINS W/ MINERALS TAB ER** *MULTIPLE VITAMINS W/ MINERALS TAB ER** PYRANTEL PAMOATE SUSP 144 MG/ML (50 MG/ML BASE EQUIV) LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML** SIMETHICONE SUSP 40 MG/0.6ML INTERFERON BETA-1A IM PREFILLED SYRINGE KIT 30 MCG/0.5ML Y DOCUSATE SODIUM CAP 100 MG *LANCETS*** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG ISOSORBIDE DINITRATE TAB 40 MG *MULTIPLE VITAMIN LIQUID** CARBAMIDE PEROXIDE 6.5% OTIC SOLN LEVOCARNITINE TAB 500 MG ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20 MG (BASE EQ) CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF) DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *ADHESIVE BANDAGES*** *B-COMPLEX W/ C TAB** LEVONORGESTREL TAB 1.5 MG CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG METHOTREXATE SOLN PF AUTO-INJECTOR 15 MG/0.3ML Y ISOTRETINOIN CAP 20 MG Y

Appendix F9 169 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ERYTHROMYCIN STEARATE TAB 250 MG *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** CIMETIDINE TAB 300 MG *SPECIALITY VITAMIN PRODUCT CAP** CHLORHEXIDINE GLUCONATE SOLN 2% *ADHESIVE BANDAGES*** ACETAMINOPHEN SUPPOS 120 MG *LANCETS*** IDELALISIB TAB 150 MG Y OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG Y POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG) GUAIFENESIN TAB ER 12HR 1200 MG PALIVIZUMAB IM SOLN 50 MG/0.5ML Y FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT ETOPOSIDE CAP 50 MG NYSTATIN OINT 100000 UNIT/GM CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 105 MG/0.7ML (150 MG/ML) Y DEXAMETHASONE TAB 1 MG FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-0.5 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG Y INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") MILNACIPRAN HCL TAB 100 MG Y TOLNAFTATE SOLN 1% TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1% *LANCETS*** *LANCETS*** ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 170 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MESALAMINE ENEMA 4 GM ASPIRIN TAB DELAYED RELEASE 81 MG OXYBUTYNIN TD PATCH TWICE WEEKLY 3.9 MG/24HR GUAIFENESIN TAB 400 MG *MULTIPLE VITAMINS W/ MINERALS TAB ER** THEOPHYLLINE SOLN 80 MG/15ML THIAMINE HCL TAB 100 MG *VITAMINS W/ LIPOTROPICS ELIXIR** RILUZOLE TAB 50 MG INTERFERON BETA-1A SOLN PREF SYR 22 MCG/0.5ML (12MU/ML) Y *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** EZETIMIBE TAB 10 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** *B-COMPLEX W/ C-ZN & FOLIC ACID TAB 0.8 MG*** ATENOLOL & CHLORTHALIDONE TAB 50-25 MG CETIRIZINE HCL TAB 10 MG BISMUTH SUBSALICYLATE SUSP 525 MG/15ML *OMEGA-3 FATTY ACIDS CAP 1000 MG** ACETAZOLAMIDE TAB 250 MG *MASKS*** *RESPIRATORY THERAPY SUPPLIES - MISC** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** ENALAPRIL MALEATE TAB 10 MG MECLIZINE HCL CHEW TAB 25 MG *LANCETS*** CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV) TACROLIMUS CAP 1 MG PROPAFENONE HCL CAP ER 12HR 225 MG VORICONAZOLE TAB 200 MG Y CHOLECALCIFEROL TAB 10 MCG (400 UNIT)

Appendix F9 171 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** IBUPROFEN TAB 200 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *VITAMIN MIXTURE CAP** NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG TAB 50 MG CALCIUM CARBONATE TAB 600 MG *MULTIPLE VITAMINS W/ MINERALS TAB** INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") DARBEPOETIN ALFA SOLN INJ 300 MCG/ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** GUAIFENESIN TAB 400 MG INTERFERON BETA-1A SOLN AUTO-INJ 44 MCG/0.5ML (24MU/ML) Y ASPIRIN TAB 325 MG ASPIRIN TAB 500 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *B-COMPLEX W/ FOLIC ACID CAP** INTERFERON BETA-1A SOLN AUTO-INJ 44 MCG/0.5ML (24MU/ML) Y BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG PSEUDOEPHEDRINE HCL TAB 30 MG SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG BENZOYL PEROXIDE GEL 5% LEVOTHYROXINE SODIUM TAB 175 MCG NONOXYNOL-9 FOAM 12.5% INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML GUAIFENESIN SYRUP 100 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4% THEOPHYLLINE CAP ER 24HR 400 MG CLOTRIMAZOLE VAGINAL CREAM 2%

Appendix F9 172 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs IBUPROFEN TAB 800 MG CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG TOLNAFTATE AEROSOL POW 1% INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML Y SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF) INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") WARFARIN SODIUM TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DIPHENHYDRAMINE HCL TAB DISINT 12.5 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** SELEXIPAG TAB 1400 MCG Y *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** TRETINOIN CREAM 0.1% Y PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM CARBAMIDE PEROXIDE 6.5% OTIC SOLN ASPIRIN TAB 325 MG *MULTIPLE VITAMINS W/ MINERALS TAB** INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") IBUPROFEN TAB 800 MG *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** *MASKS*** ASPIRIN CHEW TAB 81 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 420 MG LENVATINIB CAP THERAPY PACK 2 X 10 MG (20 MG DAILY DOSE) Y RAMIPRIL CAP 1.25 MG *BIOFLAVONOID PRODUCTS TAB** *DIAPER RASH PRODUCTS - CREAM** CYPROHEPTADINE HCL TAB 4 MG LOPERAMIDE-SIMETHICONE TAB 2-125 MG CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA) *OMEGA-3 FATTY ACIDS CAP 435 MG** NEVIRAPINE TAB 200 MG

Appendix F9 173 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG EPOETIN ALFA-EPBX INJ 4000 UNIT/ML Y DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG FENTANYL TD PATCH 72HR 100 MCG/HR Y LEVONORGESTREL TAB 1.5 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML CONDOMS LATEX LUBRICATED METFORMIN HCL TAB 500 MG HYOSCYAMINE SULFATE SOLN 0.125 MG/ML *MULTIPLE VITAMINS W/ IRON TAB** METRONIDAZOLE CREAM 0.75% CALCIUM CARBONATE-CHOLECALCIFEROL CHEW TAB 500 MG-400 UNIT POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP DARBEPOETIN ALFA SOLN INJ 40 MCG/ML Y CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG Y RIVAROXABAN TAB 2.5 MG ALMOND OIL (SWEET) CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG *MULTIPLE VITAMIN TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *ALCOHOL SWABS*** OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML) Y CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG ACETAMINOPHEN SOLN 160 MG/5ML HYPROMELLOSE PRESERVATIVE FREE (PF) OPHTH SOLN 0.3% ZIDOVUDINE SYRUP 10 MG/ML MALATHION LOTION 0.5% Y ISONIAZID TAB 300 MG

Appendix F9 174 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG PERMETHRIN CREME RINSE 1% QUINAPRIL HCL TAB 10 MG *MASKS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR DEXTROMETHORPHAN HBR-QUINIDINE SULFATE CAP 20-10 MG Y TRIAMCINOLONE ACETONIDE CREAM 0.5% ACETAMINOPHEN TAB ER 650 MG *LACTOBACILLUS CAP** PRAZOSIN HCL CAP 1 MG ESTRADIOL TAB 0.5 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** LEUCOVORIN CALCIUM TAB 5 MG *MULTIPLE VITAMINS W/ MINERALS CAP** PRAVASTATIN SODIUM TAB 10 MG FEXOFENADINE HCL TAB 60 MG PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG RIBAVIRIN TAB 200 MG Y LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG CALCIUM-MAGNESIUM-ZINC TAB 333-133-5 MG LEVOTHYROXINE SODIUM TAB 75 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES TAB 25 MG PSEUDOEPHEDRINE HCL TAB 30 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG *MULTIPLE VITAMIN TAB** *LANCETS*** BISMUTH SUBSALICYLATE SUSP 262 MG/15ML CHLORPHENIRAMINE MALEATE TAB 4 MG GUAIFENESIN SYRUP 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** SAPROPTERIN DIHYDROCHLORIDE SOLUBLE TAB 100 MG Y

Appendix F9 175 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ORAL ELECTROLYTE SOLUTION*** ASPIRIN TAB DELAYED RELEASE 81 MG CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT) Y *LANCETS*** INSULIN NPH & REGULAR SUSP PEN-INJ 100 UNIT/ML (70-30) *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA) ACETAMINOPHEN CHEW TAB 160 MG *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS CAP** METRONIDAZOLE TAB 250 MG *MULTIPLE VITAMINS W/ MINERALS TAB ER** VALSARTAN TAB 80 MG *LACTOBACILLUS CAP** *VITAMIN MIXTURE CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** LINEZOLID IN SODIUM CHLORIDE IV SOLN 600 MG/300ML-0.9% Y DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML *PRENATAL VIT W/ DSS-FE CBN-FE GLUC-FA TAB 90-1 MG*** *ADHESIVE BANDAGES*** FOLIC ACID TAB 400 MCG OXYCODONE HCL TAB 5 MG Y MORPHINE SULFATE TAB ER 60 MG Y PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG *BIOFLAVONOID PRODUCTS TAB** *ADHESIVE BANDAGES*** *ARTIFICIAL TEAR OPHTH SOLUTION*** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG CHOLECALCIFEROL DROPS 10 MCG/0.028ML (400 UNIT/0.028ML) LEVOTHYROXINE SODIUM TAB 200 MCG

Appendix F9 176 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG *ALCOHOL SHEETS*** MELATONIN TAB ER 10 MG OMEPRAZOLE MAGNESIUM CAP DR 20.6 MG (20 MG BASE EQUIV) TRIMETHOPRIM TAB 100 MG *MULTIPLE VITAMINS W/ MINERALS CAP** BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG LEVOTHYROXINE SODIUM TAB 25 MCG PSEUDOEPHEDRINE HCL TAB 30 MG LORATADINE SYRUP 5 MG/5ML CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-500 UNIT *MULTIPLE VITAMINS W/ MINERALS CAP** BISACODYL TAB DELAYED RELEASE 5 MG LUMACAFTOR-IVACAFTOR GRANULES PACKET 150-188 MG Y NIFEDIPINE TAB ER 24HR 60 MG DEXAMETHASONE TAB 4 MG PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4% *ADHESIVE BANDAGES*** ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) Y *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** *SALINE W/ PHENOL INJ*** *LACTOBACILLUS CAP** ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG *LANCETS*** *ADHESIVE BANDAGES*** THEOPHYLLINE CAP ER 24HR 100 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ENTECAVIR TAB 1 MG PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 15 MG (BASE EQ) SOTALOL HCL TAB 240 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CIMETIDINE TAB 200 MG *B-COMPLEX W/ C & E + ZN TAB***

Appendix F9 177 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NITROGLYCERIN OINT 2% *ADHESIVE BANDAGES*** TAB 25 MG CALCIUM CARBONATE (ANTACID) SUSP 1250 MG/5ML HYDRALAZINE HCL TAB 10 MG *ALCOHOL SWABS*** DIPHENHYDRAMINE HCL TAB 25 MG *SPECIALITY VITAMIN PRODUCT EFFER TAB** HYOSCYAMINE SULFATE TAB 0.125 MG *ADHESIVE BANDAGES - PADS*** FLUTICASONE FUROATE AEROSOL POWDER BREATH ACTIV 200 MCG/ACT *ADHESIVE BANDAGES*** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG FLUTICASONE FUROATE AEROSOL POWDER BREATH ACTIV 200 MCG/ACT *SPECIALITY VITAMIN PRODUCT TAB** ALLOPURINOL TAB 100 MG DOLUTEGRAVIR SODIUM TAB 10 MG (BASE EQUIV) MORPHINE SULFATE TAB ER 15 MG Y DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML SALINE NASAL SOLN 0.65% *MULTIPLE VITAMINS W/ MINERALS TAB** DIPHENHYDRAMINE HCL TAB 25 MG MICONAZOLE NITRATE VAGINAL CREAM 2% *ORAL ELECTROLYTE SOLUTION*** BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG DIGOXIN TAB 125 MCG (0.125 MG) GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML Y *B-COMPLEX W/ FOLIC ACID TAB** OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2.5-18.5 LF-LF-MCG/0.5ML

Appendix F9 178 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs TET TOX-DIPH-ACELL PERTUSS AD INJ 5-2.5-18.5 LF-LF-MCG/0.5ML *VITAMINS C & E CAP*** GUAIFENESIN SYRUP 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** SEMAGLUTIDE SOLN PEN-INJ 0.25 OR 0.5 MG/DOSE (2 MG/1.5ML) Y *ADHESIVE BANDAGES*** POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML) GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG ETRAVIRINE TAB 200 MG PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG DIPHENHYDRAMINE HCL TAB 25 MG GLYCERIN-HYPROMELLOSE-PEG 400 OPHTH SOLN 0.2-0.2-1% SIMETHICONE LIQUID 40 MG/0.6ML POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ *MULTIPLE VITAMINS W/ MINERALS TAB** ALBUTEROL SULFATE TAB ER 12HR 8 MG *VITAMINS W/ LIPOTROPICS TAB ER** LIDOCAINE PATCH 5% Y ACETAMINOPHEN W/ CODEINE TAB 300-60 MG Y TRIAMCINOLONE ACETONIDE CREAM 0.1% *COD LIVER OIL CAP*** DIPHENHYDRAMINE HCL TAB 25 MG PHENYTOIN SODIUM EXTENDED CAP 100 MG ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR IBUPROFEN CAP 200 MG *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** DEXTRAN 70-HYPROMELLOSE (PF) OPHTH SOLN 0.1-0.3% DOCUSATE SODIUM CAP 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML FLAXSEED OIL (LINSEED OIL) MELATONIN TAB 5 MG ACETAMINOPHEN TAB ER 650 MG

Appendix F9 179 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT METFORMIN HCL TAB 850 MG SIMETHICONE CHEW TAB 125 MG DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) HYDROCORTISONE SOLN 1% SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CONDOMS LATEX LUBRICATED ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML FOLIC ACID TAB 800 MCG DIPHENHYDRAMINE HCL TAB 25 MG CONDOMS LATEX LUBRICATED *LANCETS*** *LANCETS*** *LANCETS*** CARBIDOPA & LEVODOPA TAB ER 25-100 MG *MULTIPLE VITAMIN TAB** EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000) LISINOPRIL TAB 5 MG ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250 MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG *LANCETS*** *LACTOBACILLUS CAP** ESTRADIOL TAB 2 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FAMOTIDINE TAB 20 MG *MULTIPLE VITAMINS W/ MINERALS TAB** SPIRONOLACTONE TAB 25 MG *ALCOHOL SWABS*** *SPECIALITY VITAMIN PRODUCT TAB** GUAIFENESIN-CODEINE LIQUID 200-10 MG/5ML OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML) Y

Appendix F9 180 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") *B-COMPLEX VITAMIN TAB** *LANCETS*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** BISACODYL TAB DELAYED RELEASE 5 MG DIPYRIDAMOLE TAB 25 MG EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** ACETAMINOPHEN SUPPOS 325 MG HYDROCORTISONE BUTYRATE OINT 0.1% *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** TIPRANAVIR CAP 250 MG *MULTIPLE VITAMINS W/ MINERALS TAB** BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT Y INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") BETAMETHASONE VALERATE LOTION 0.1% (BASE EQUIVALENT) *COD LIVER OIL*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV) POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% TOLNAFTATE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS TAB** PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** *ADHESIVE BANDAGES*** *ORAL ELECTROLYTE SOLUTION***

Appendix F9 181 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs NIACIN W/ INOSITOL CAP 400-100 MG *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** GEMFIBROZIL TAB 600 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *LANCETS*** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *LANCETS*** *OMEGA-3 FATTY ACIDS CAP 1200 MG** CALCIUM CARBONATE-MAG HYDROXIDE SUSP 400-135 MG/5ML SENNOSIDES TAB 25 MG *LANCETS*** *LANCETS*** RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT) Y *BIOFLAVONOID PRODUCTS TAB ER** *BIOFLAVONOID PRODUCTS TAB** TOBRAMYCIN NEBU SOLN 300 MG/5ML Y MELATONIN TAB 3 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *BIOFLAVONOID PRODUCTS TAB ER** ACETAMINOPHEN TAB 325 MG NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN *LANCETS*** DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG MELATONIN TAB 5 MG SULFACETAMIDE SODIUM OPHTH SOLN 10% *LANCETS*** IBUPROFEN CHEW TAB 100 MG HYDROCORTISONE OINT 1% DILTIAZEM HCL TAB 90 MG *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") BETHANECHOL CHLORIDE TAB 5 MG

Appendix F9 182 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *BIOFLAVONOID PRODUCTS TAB ER** CHOLECALCIFEROL TAB 10 MCG (400 UNIT) GUAIFENESIN TAB 400 MG ACETAMINOPHEN CHEW TAB 80 MG *MASKS*** *MULTIPLE VITAMINS W/ MINERALS TAB** OMEPRAZOLE MAGNESIUM DELAYED RELEASE TAB 20 MG (BASE EQUIV) LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML) Y IBUPROFEN SUSP 100 MG/5ML CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-600 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT) Y DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 420 MG ISOTRETINOIN CAP 10 MG Y *MULTIPLE VITAMINS W/ MINERALS POWDER** *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** MELATONIN TAB 5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *ORAL ELECTROLYTE SOLUTION*** PYRIDOSTIGMINE BROMIDE ORAL SOLN 60 MG/5ML *MULTIPLE VITAMINS W/ MINERALS PACK** TACROLIMUS CAP 5 MG GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 120 MG/ML Y *LANCETS*** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** HYDROCORTISONE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS LIQUID** CLOTRIMAZOLE CREAM 1% IBUPROFEN CAP 200 MG POVIDONE-IODINE SOLN 10% *ORAL ELECTROLYTE SOLUTION*** ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML Y

Appendix F9 183 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs MELATONIN TAB 5 MG NEVIRAPINE TAB ER 24HR 400 MG COLESTIPOL HCL GRANULE PACKETS 5 GM COLESTIPOL HCL GRANULES 5 GM MECLIZINE HCL CHEW TAB 25 MG SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG FLUCONAZOLE TAB 200 MG *MULTIPLE VITAMINS W/ MINERALS PACK** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG MECLIZINE HCL TAB 25 MG IBUPROFEN TAB 200 MG SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML*** *LANCETS*** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS COMBINATION THERAPY PACK*** *MULTIPLE VITAMINS W/ MINERALS PACK** EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 150 MG/ML Y *B-COMPLEX W/ FOLIC ACID TAB** DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG *LANCETS*** NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1% MELATONIN TAB ER 3 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG FEXOFENADINE HCL TAB 180 MG *SPECIALITY VITAMIN PRODUCT CAP** MORPHINE SULFATE ORAL SOLN 10 MG/5ML Y ISOTRETINOIN CAP 40 MG Y ACETAMINOPHEN DISINTEGRATING TAB 80 MG *LACTOBACILLUS RHAMNOSUS (GG) LIQUID** *RESPIRATORY THERAPY SUPPLIES - MISC** *ADHESIVE BANDAGES***

Appendix F9 184 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *BIOFLAVONOID PRODUCTS TAB** *ADHESIVE BANDAGES*** *MULTIPLE VITAMIN TAB** DIPHENHYDRAMINE HCL CAP 25 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** CHLORHEXIDINE GLUCONATE LIQUID 2% NYSTATIN TAB 500000 UNIT FLUTAMIDE CAP 125 MG LEUPROLIDE ACETATE INJ KIT 5 MG/ML Y ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV) Y CALCIUM W/ VITAMIN D TAB 600 MG-200 UNIT NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1% AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG SALINE NASAL AEROSOL SOLN 0.9% DEXTRAN 70-HYPROMELLOSE (PF) OPHTH SOLN 0.1-0.3% MICONAZOLE NITRATE CREAM 2% LEVOTHYROXINE SODIUM TAB 50 MCG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML APREPITANT CAPSULE 40 MG Y *ALCOHOL SWABS*** *MULTIPLE VITAMINS W/ MINERALS CAP** *LANCETS*** FERROUS SULFATE DRIED TAB ER 45 MG (FE EQUIVALENT) FENTANYL TD PATCH 72HR 75 MCG/HR Y IBUPROFEN TAB 600 MG ENOXAPARIN SODIUM INJ 300 MG/3ML *MULTIPLE VITAMINS W/ IRON TAB** SIMETHICONE CAP 180 MG ACETAMINOPHEN TAB 325 MG CETIRIZINE HCL CHEW TAB 5 MG *MULTIPLE VITAMIN CAP**

Appendix F9 185 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs VALSARTAN TAB 40 MG *LACTOBACILLUS RHAMNOSUS (GG) LIQUID** *VITAMINS W/ LIPOTROPICS TAB** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *SPECIALITY VITAMIN PRODUCT CAP** BISMUTH SUBSALICYLATE CHEW TAB 262 MG PRIMIDONE TAB 250 MG CARBAMIDE PEROXIDE 6.5% OTIC SOLN *MASKS*** *DIAPER RASH PRODUCTS - OINTMENT** *VITAMINS W/ LIPOTROPICS TAB** CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** CHOLECALCIFEROL CHEW TAB 25 MCG (1000 UNIT) INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") SENNOSIDES TAB 25 MG LEVOTHYROXINE SODIUM TAB 200 MCG *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMIN TAB** CEFADROXIL TAB 1 GM *VITAMINS W/ LIPOTROPICS TAB** TRETINOIN GEL 0.01% Y IBUPROFEN TAB 200 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") ACETAZOLAMIDE TAB 125 MG *MASKS*** IBUPROFEN TAB 600 MG MICONAZOLE NITRATE VAGINAL CREAM 2% TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG *MULTIPLE VITAMINS W/ MINERALS TAB** WARFARIN SODIUM TAB 7.5 MG

Appendix F9 186 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs BACITRACIN-POLYMYXIN B OPHTH OINT SODIUM FLUORIDE CREAM 1.1% INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64" *ADHESIVE BANDAGES*** VORICONAZOLE TAB 50 MG Y SODIUM FLUORIDE TAB 0.5 MG F (FROM 1.1 MG NAF) EPOETIN ALFA-EPBX INJ 3000 UNIT/ML Y GUAIFENESIN LIQUID 100 MG/5ML *SPECIALITY VITAMIN PRODUCT TAB** DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML ENALAPRIL MALEATE TAB 20 MG RAMIPRIL CAP 2.5 MG CHOLECALCIFEROL TAB 125 MCG (5000 UNIT) CLOTRIMAZOLE VAGINAL CREAM 1% IBUPROFEN TAB 200 MG CEPHALEXIN CAP 250 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *LANCETS*** SALINE NASAL SPRAY 0.65% *LANCETS*** *LANCETS*** DIPYRIDAMOLE TAB 50 MG TRIMETHOBENZAMIDE HCL CAP 300 MG FLUOCINOLONE ACETONIDE SOLN 0.01% *VAPORIZERS*** LIDOCAINE-PRILOCAINE CREAM 2.5-2.5% ASPIRIN TAB DELAYED RELEASE 81 MG INTERFERON BETA-1B FOR INJ KIT 0.3 MG Y *BIOFLAVONOID PRODUCTS CAP** *LANCETS*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CAP** *ADHESIVE BANDAGES***

Appendix F9 187 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs GLYCINE DILUENT FOR INJECTION CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT SIMETHICONE CAP 125 MG *DIAPER RASH PRODUCTS - OINTMENT** *LANCETS*** *B-COMPLEX W/ C & FOLIC ACID TAB*** GUAIFENESIN TAB 400 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT LACTIC ACID (AMMONIUM LACTATE) CREAM 12% *VITAMINS W/ LIPOTROPICS TAB ER** *MULTIPLE VITAMIN TAB** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *MULTIPLE VITAMIN TAB** SENNOSIDES TAB 17.2 MG PANOBINOSTAT LACTATE CAP 10 MG (BASE EQUIVALENT) Y OXYCODONE HCL TAB 10 MG Y FINASTERIDE TAB 5 MG CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML QUINAPRIL HCL TAB 5 MG CETIRIZINE HCL TAB 10 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ACETAMINOPHEN CHEW TAB 160 MG ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR *IRON W/ VITAMIN TAB** PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) ASPIRIN CHEW TAB 81 MG CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG *ADHESIVE BANDAGES - PADS***

Appendix F9 188 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** CARBOXYMETHYLCELLULOSE-GLYCERIN OPHTH SOLN 0.5-0.9% RIBAVIRIN CAP 200 MG Y FUROSEMIDE ORAL SOLN 10 MG/ML SODIUM CHLORIDE SOLN NEBU 3% *VITAMINS W/ LIPOTROPICS TAB ER** SIMETHICONE CHEW TAB 80 MG ESTRADIOL TAB 1 MG LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML) *ORAL ELECTROLYTE SOLUTION*** FERROUS SULFATE TAB ER 47.5 MG (ELEMENTAL FE) SIMVASTATIN TAB 5 MG DIDANOSINE DELAYED RELEASE CAPSULE 400 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG *LANCETS*** *B-COMPLEX W/ C & E + ZN TAB*** METHOCARBAMOL TAB 750 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** ANTIHEMOPHILIC FACTOR RECOM PEGYLATED-AUCL FOR INJ 2000 UNIT Y SODIUM FLUORIDE SOLN 0.25 MG/DROP F (FROM 0.55 MG/DROP NAF) FAMOTIDINE TAB 20 MG *ADHESIVE BANDAGES*** ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.25 MG/DAY BISACODYL TAB DELAYED RELEASE 5 MG BENZOYL PEROXIDE GEL 10% CHOLECALCIFEROL ORAL LIQUID 10 MCG/ML (400 UNIT/ML) INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG DARBEPOETIN ALFA SOLN INJ 60 MCG/ML Y

Appendix F9 189 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") DIPHENHYDRAMINE HCL CAP 25 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG SODIUM FLUORIDE RINSE 0.2% *LANCETS*** ACETAMINOPHEN SUPPOS 650 MG EFAVIRENZ CAP 50 MG CETIRIZINE HCL TAB 10 MG GUAIFENESIN GRANULES PACKET 100 MG CALCIUM W/ VITAMIN D TAB 500 MG-125 UNIT *ARTIFICIAL TEAR OPHTH SOLUTION*** AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT) CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG NONOXYNOL-9 VAGINAL SUPPOS 100 MG LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) AMANTADINE HCL TAB 100 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS EFFER TAB** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** *MICONAZOLE NIT VA APP 100 MG (2%) & 2% CREAM & WIPES KIT* *MICONAZOLE NITRATE VA SUPP 200 MG & 2% CREAM & WIPES KIT** OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG LEVONORGESTREL TAB 1.5 MG ULIPRISTAL ACETATE TAB 30 MG OYSTER SHELL CALCIUM TAB 500 MG *LACTOBACILLUS CAP** IBUPROFEN SUSP 40 MG/ML BISMUTH SUBSALICYLATE CHEW TAB 262 MG MOMETASONE FUROATE SOLUTION 0.1% (LOTION) DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 300 MCG/0.6ML Y CETIRIZINE HCL TAB 10 MG

Appendix F9 190 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *VITAMINS A & D W/ C CHEW TAB*** DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** NIFEDIPINE TAB ER 24HR 30 MG URSODIOL CAP 300 MG THIAMINE HCL TAB 50 MG NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG LINEZOLID IV SOLN 600 MG/300ML (2 MG/ML) Y ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 5 MG Y DIGOXIN TAB 125 MCG (0.125 MG) HYDROCORTISONE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** LORATADINE ORALLY DISINTEGRATING TAB 5 MG LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT HYDROCORTISONE-ALOE VERA CREAM 1% ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** MICONAZOLE NITRATE VAGINAL CREAM 2% BUMETANIDE TAB 1 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ENOXAPARIN SODIUM INJ 150 MG/ML ISOSORBIDE DINITRATE TAB 20 MG NAPROXEN TAB 375 MG *B-COMPLEX W/ C & E + ZN TAB*** *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS TAB** VANDETANIB TAB 300 MG Y CIMETIDINE TAB 400 MG *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS TAB** *ORAL ELECTROLYTE SOLUTION***

Appendix F9 191 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs IBUPROFEN CAP 200 MG ACETAMINOPHEN CHEW TAB 80 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ IRON TAB** FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML *MULTIPLE VITAMIN TAB** CHOLECALCIFEROL TAB 10 MCG (400 UNIT) DOXERCALCIFEROL CAP 2.5 MCG *MULTIPLE VITAMINS W/ MINERALS CAP** SENNOSIDES TAB 17.2 MG CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG Y MOMETASONE FUROATE CREAM 0.1% ALENDRONATE SODIUM TAB 5 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG DEXAMETHASONE TAB 6 MG PROMETHAZINE HCL TAB 12.5 MG ASPIRIN CHEW TAB 81 MG PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT) *B-COMPLEX W/ C TAB** CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLN 0.5% *BIOFLAVONOID PRODUCTS CAP** *OMEGA-3 FATTY ACIDS CAP 1000 MG** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML VERAPAMIL HCL CAP ER 24HR 300 MG HYDROCORTISONE GEL 1% *MULTIPLE VITAMINS W/ MINERALS TAB** *ACETIC ACID VAGINAL SOLUTION** ACETAMINOPHEN TAB 325 MG ACETAMINOPHEN TAB 500 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS LOZENGE***

Appendix F9 192 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs PSEUDOEPHEDRINE HCL TAB ER 12HR 120 MG METHAZOLAMIDE TAB 25 MG INSULIN PEN NEEDLE 31 G X 5 MM (1/5" OR 3/16") HYDROCORTISONE OINT 1% CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) METFORMIN HCL TAB 1000 MG *ADHESIVE BANDAGES*** *LANCETS*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") CALCIUM CARBONATE-VITAMIN D TAB 600 MG-125 UNIT *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** HYDROCORTISONE-ALOE VERA CREAM 1% NORETHINDRONE TAB 0.35 MG ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV) HYDROCORTISONE LOTION 2.5% IBUPROFEN CAP 200 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** CALCIUM CARBONATE (ANTACID) CHEW TAB 420 MG *ADHESIVE BANDAGES*** CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) BENZYL ALCOHOL SOMATROPIN INJ 5 MG/1.5ML Y ACETIC ACID OTIC SOLN 2% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** CHLORHEXIDINE GLUCONATE SOLN 0.12% FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) *OMEGA-3 FATTY ACIDS - ORAL LIQUID** OXAPROZIN TAB 600 MG *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH GEL 1%

Appendix F9 193 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CROMOLYN SODIUM OPHTH SOLN 4% CHLORPHENIRAMINE MALEATE TAB 4 MG ACETAMINOPHEN SUSP 160 MG/5ML ETRAVIRINE TAB 100 MG LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** BISACODYL TAB DELAYED RELEASE 5 MG *MULTIPLE VITAMINS W/ MINERALS CAP** NONOXYNOL-9 GEL 3% FENOFIBRATE MICRONIZED CAP 200 MG UMECLIDINIUM BR AERO POWD BREATH ACT 62.5 MCG/INH (BASE EQ) *LANCETS*** *LANCETS*** *LANCETS*** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** FUROSEMIDE TAB 20 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** ACETAMINOPHEN SUSP 160 MG/5ML *B-COMPLEX W/BIOTIN & FOLIC ACID CAP*** MELATONIN TABLET DISINTEGRATING 10 MG SENNOSIDES TAB 8.6 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML SELEGILINE HCL TAB 5 MG UMECLIDINIUM BR AERO POWD BREATH ACT 62.5 MCG/INH (BASE EQ) FERROUS FUMARATE TAB 324 MG (106 MG ELEMENTAL FE) DOCUSATE SODIUM TAB 100 MG DANTROLENE SODIUM CAP 25 MG *OMEGA-3 FATTY ACIDS CAP 1000 MG** *VITAMINS W/ LIPOTROPICS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CAPSAICIN CREAM 0.033%

Appendix F9 194 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/BIOTIN & FOLIC ACID CAP*** *MULTIPLE VITAMIN TAB** PREDNISONE TAB 2.5 MG BISMUTH SUBSALICYLATE SUSP 262 MG/15ML *LANCETS*** ROPINIROLE HYDROCHLORIDE TAB 5 MG TORSEMIDE TAB 10 MG *ADHESIVE BANDAGES*** CALCITRIOL CAP 0.5 MCG LEVOTHYROXINE SODIUM TAB 137 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.25% DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG *MASKS*** *OMEGA-3 FATTY ACIDS CAP 1200 MG** FAMCICLOVIR TAB 125 MG *MASKS*** ATENOLOL TAB 25 MG BETHANECHOL CHLORIDE TAB 10 MG *LANCETS*** NAPROXEN SODIUM CAP 220 MG TRIAMCINOLONE ACETONIDE CREAM 0.5% *MULTIPLE VITAMINS W/ MINERALS CAP** ISOTRETINOIN CAP 40 MG Y *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) Y HYDROCORTISONE SOLN 1% *B-COMPLEX W/ C CAP** FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT THIAMINE HCL TAB 100 MG

Appendix F9 195 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") *ADHESIVE BANDAGES*** ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *CONDOMS - MALE*** *MULTIPLE VITAMINS W/ MINERALS TAB** THEOPHYLLINE TAB ER 12HR 300 MG *MULTIPLE VITAMINS W/ MINERALS TAB** SODIUM FLUORIDE TAB 1 MG F (FROM 2.2 MG NAF) TIPRANAVIR ORAL SOLN 100 MG/ML *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT) POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% *MULTIPLE VITAMINS W/ MINERALS TAB** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-800 UNIT DEXAMETHASONE TAB 2 MG *VITAMIN MIXTURE TAB** FAMOTIDINE TAB 20 MG TOLNAFTATE SOLN 1% HYDRALAZINE HCL TAB 100 MG *CONDOMS - FEMALE*** CALCIUM-ERGOCALCIFEROL TAB 500 MG-200 UNIT *ADHESIVE BANDAGES*** *MULTIPLE VITAMINS W/ MINERALS POWDER** *RESPIRATORY THERAPY SUPPLIES - MISC** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML ETODOLAC TAB ER 24HR 400 MG DOLUTEGRAVIR SODIUM TAB 25 MG (BASE EQUIV) PERMETHRIN AEROSOL 0.5% HYDROCORTISONE-ALOE VERA CREAM 1%

Appendix F9 196 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *ALCOHOL SWABS*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN *RESPIRATORY THERAPY SUPPLIES - MISC** ISOSORBIDE MONONITRATE TAB 20 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CARBAMIDE PEROXIDE 6.5% OTIC SOLN GUAIFENESIN TAB 400 MG NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG *MULTIPLE VITAMINS W/ MINERALS CAP** ACETAMINOPHEN TAB 325 MG *MULTIPLE VITAMIN CHEW TAB** HYDROCORTISONE ACETATE OINT 1% *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** FOR INJ 400 UNIT Y *OMEGA-3 FATTY ACIDS CHEW TAB 113.5 MG** DIFLUNISAL TAB 500 MG *VITAMINS A & D CAP*** *LANCETS*** LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 30 MG (BASE EQ) ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 197 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *OMEGA-3 FATTY ACIDS CAP 1200 MG** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML MECLIZINE HCL CHEW TAB 25 MG *LACTOBACILLUS RHAMNOSUS (GG) CAP** DOXYLAMINE SUCCINATE (SLEEP) TAB 25 MG MICONAZOLE NITRATE CREAM 2% GLYCERIN-HYPROMELLOSE-PEG 400 OPHTH SOLN 0.2-0.2-1% DESOXIMETASONE GEL 0.05% *LANCETS*** DESOXIMETASONE CREAM 0.25% DOCUSATE SODIUM CAP 100 MG *MULTIPLE VITAMINS W/ MINERALS CAP** HYDROCORTISONE CREAM 1% *MULTIPLE VITAMINS W/ MINERALS TAB** BACITRACIN OINT 500 UNIT/GM TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML) Y *B-COMPLEX VITAMIN ELIXIR** SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") SODIUM CHLORIDE SOLN NEBU 7% BENZOYL PEROXIDE GEL 10% METHADONE HCL TAB 5 MG Y PHENOBARBITAL TAB 16.2 MG *LANCETS*** LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML TRIAMCINOLONE ACETONIDE LOTION 0.025% LEVOTHYROXINE SODIUM TAB 75 MCG *LANCETS*** ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML & 40 MG/0.4ML Y ACETAMINOPHEN SOLN 160 MG/5ML

Appendix F9 198 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs INSULIN PEN NEEDLE 32 G X 6 MM (1/4" OR 15/64") FEXOFENADINE HCL TAB 60 MG ASPIRIN CHEW TAB 81 MG *ADHESIVE BANDAGES*** SIMETHICONE CHEW TAB 80 MG DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML NAPROXEN SODIUM TAB 220 MG SALINE NASAL SPRAY 0.2% *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 81 MG DOXYCYCLINE HYCLATE CAP 100 MG DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML *LANCETS*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML *ADHESIVE BANDAGES - PADS*** PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) *MULTIPLE VITAMINS W/ MINERALS TAB** ERYTHROMYCIN OPHTH OINT 5 MG/GM *MULTIPLE VITAMINS W/ MINERALS TAB** VALSARTAN TAB 320 MG FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG *MULTIPLE VITAMINS W/ MINERALS PACK** DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% Y CALCIUM CARBONATE-VITAMIN D CHEW TAB 600 MG-400 UNIT OXYCODONE HCL TAB 15 MG Y *SPECIALITY VITAMIN PRODUCT CAP** SELEXIPAG TAB 1200 MCG Y *RESPIRATORY THERAPY SUPPLIES - MISC** *MULTIPLE VITAMINS W/ MINERALS LIQUID** EPOETIN ALFA-EPBX INJ 2000 UNIT/ML Y MITOTANE TAB 500 MG ACETAMINOPHEN TAB ER 650 MG *MULTIPLE VITAMINS W/ MINERALS CAP**

Appendix F9 199 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML KETOCONAZOLE SHAMPOO 2% IBUPROFEN CHEW TAB 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML PREDNISOLONE ACETATE OPHTH SUSP 1% PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1% ETANERCEPT FOR SUBCUTANEOUS INJ 25 MG Y NYSTATIN CREAM 100000 UNIT/GM PRIMIDONE TAB 50 MG METRONIDAZOLE GEL 0.75% *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG*** LANSOPRAZOLE CAP DELAYED RELEASE 15 MG DILTIAZEM HCL TAB 60 MG HYDROCORTISONE PERIANAL CREAM 2.5% RIVAROXABAN TAB 20 MG PROPYLENE GLYCOL-GLYCERIN OPHTH SOLN 1-0.3% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** MICONAZOLE NITRATE POWDER 2% *MULTIPLE VITAMINS W/ MINERALS PACK** *B-COMPLEX W/ C TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG SILVER SULFADIAZINE CREAM 1% CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-500 UNIT *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** CETIRIZINE HCL CHEW TAB 10 MG

Appendix F9 200 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *B-COMPLEX W/ C & CALCIUM TAB*** NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG CHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMIN TAB** *MULTIPLE VITAMIN TAB** ACETAMINOPHEN TAB 500 MG VORICONAZOLE FOR SUSP 40 MG/ML Y SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 25 MG/2.5ML Y *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** LINACLOTIDE CAP 145 MCG TERBINAFINE HCL TAB 250 MG CHOLECALCIFEROL CAP 50 MCG (2000 UNIT) NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *ADHESIVE BANDAGES*** *VAPORIZERS*** TRANDOLAPRIL TAB 2 MG LEVOFLOXACIN OPHTH SOLN 0.5% IBUPROFEN TAB 400 MG *MULTIPLE VITAMINS W/ MINERALS CAP** AMBRISENTAN TAB 5 MG Y BISMUTH SUBSALICYLATE CHEW TAB 262 MG *ADHESIVE BANDAGES*** NORETHINDRONE TAB 0.35 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** POVIDONE-IODINE SOLN 10% HYDROCHLOROTHIAZIDE CAP 12.5 MG CARBIDOPA & LEVODOPA TAB 25-250 MG *LANCETS*** IBUPROFEN TAB 200 MG BISACODYL TAB DELAYED RELEASE 5 MG LEVOTHYROXINE SODIUM TAB 100 MCG

Appendix F9 201 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** ALUM & MAG HYDROXIDE-SIMETHICONE CHEW TAB 200-200-25 MG *LANCETS*** SIMETHICONE CHEW TAB 125 MG CEPHALEXIN CAP 750 MG CALCIUM CARBONATE-CHOLECALCIFEROL CHEW TAB 500 MG-600 UNIT CLARITHROMYCIN TAB 250 MG CALCIUM CITRATE-VITAMIN D TAB 200 MG-250 UNIT (ELEMENTAL CA) CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML ASPIRIN TAB 325 MG MILNACIPRAN HCL TAB 25 MG Y MEBENDAZOLE CHEW TAB 100 MG *MULTIPLE VITAMINS W/ MINERALS CAP** *MULTIPLE VITAMINS W/ MINERALS CAP** AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") HYDROCORTISONE LOTION 1% PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM *VITAMINS W/ LIPOTROPICS TAB** DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG SPINOSAD SUSP 0.9% Y TRETINOIN CREAM 0.025% Y *MULTIPLE VITAMINS W/ MINERALS CAP** BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05% LACTULOSE SOLUTION 10 GM/15ML POLYETHYLENE GLYCOL 3350 ORAL POWDER 17 GM/SCOOP CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 150 MCG/0.3ML Y SOMATROPIN INJ 30 MG/3ML Y

Appendix F9 202 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CONDOMS LATEX LUBRICATED DIDANOSINE DELAYED RELEASE CAPSULE 250 MG IBUPROFEN TAB 200 MG MELATONIN LIQUID 3.5 MG/2ML (1.75 MG/ML) SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML AZATHIOPRINE TAB 50 MG *MULTIPLE VITAMINS W/ MINERALS TAB** CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) POVIDONE-IODINE SOLN 10% *MASKS*** PROPRANOLOL HCL CAP ER 24HR 160 MG POVIDONE-IODINE SOLN 10% DOCUSATE SODIUM SYRUP 60 MG/15ML OMEPRAZOLE-SODIUM BICARBONATE CAP 20-1100 MG MILNACIPRAN HCL TAB 12.5 MG Y *MULTIPLE VITAMINS W/ MINERALS TAB** ATOVAQUONE SUSP 750 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** ACETAMINOPHEN ELIXIR 160 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** *LANCETS*** IBUPROFEN TAB 400 MG CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-200 UNIT-40 MCG ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** METHOCARBAMOL TAB 500 MG ACETAMINOPHEN CHEW TAB 80 MG DEXTRAN 70-HYPROMELLOSE (PF) OPHTH SOLN 0.1-0.3% CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG METHYLPREDNISOLONE TAB 2 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG

Appendix F9 203 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ACETAMINOPHEN SOLN 160 MG/5ML CARBAMIDE PEROXIDE 6.5% OTIC SOLN TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML) Y *PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1.25 MG*** *ORAL ELECTROLYTE SOLUTION*** *LANCETS*** DESONIDE CREAM 0.05% *LANCETS*** DILTIAZEM HCL CAP ER 12HR 60 MG *LANCETS*** HYDROXYPROGESTERONE CAPROATE IM IN OIL 250 MG/ML Y HYDROCORTISONE CREAM 1% BISMUTH SUBSALICYLATE CHEW TAB 262 MG CARBIDOPA & LEVODOPA TAB 25-100 MG INSULIN PEN NEEDLE 29 G X 12.7 MM (1/2") *MULTIPLE VITAMINS W/ MINERALS TAB** MELATONIN TAB 200 MCG NABUMETONE TAB 500 MG *MULTIPLE VITAMINS W/ MINERALS TAB** ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.2ML Y FERROUS GLUCONATE TAB 324 MG (37.5 MG ELEMENTAL IRON) AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML *RESPIRATORY THERAPY SUPPLIES - MISC** BOSENTAN TAB 125 MG Y MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML IBUPROFEN CHEW TAB 100 MG FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-500 UNIT-40 MCG SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG CALCIUM W/ VITAMIN D & K CHEW TAB 500 MG-500 UNIT-40 MCG DOXERCALCIFEROL CAP 1 MCG

Appendix F9 204 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS TAB** PHYTONADIONE TAB 5 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *ADHESIVE BANDAGES*** *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** *MULTIPLE VITAMINS W/ MINERALS POWDER** LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) *ADHESIVE BANDAGES*** LEVONORGESTREL TAB 1.5 MG RUXOLITINIB PHOSPHATE TAB 15 MG (BASE EQUIVALENT) Y *MULTIPLE VITAMINS W/ MINERALS CAP** *B-COMPLEX W/ C & FOLIC ACID TAB ER*** METHOTREXATE SOLN PF AUTO-INJECTOR 20 MG/0.4ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/ C TAB** NABUMETONE TAB 750 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG *ADHESIVE BANDAGES*** ACETAMINOPHEN CHEW TAB 160 MG CYCLOBENZAPRINE HCL TAB 10 MG BISMUTH SUBSALICYLATE TAB 262 MG DIPHENHYDRAMINE HCL CAP 25 MG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) *MULTIPLE VITAMIN TAB** HALOBETASOL PROPIONATE CREAM 0.05% VALGANCICLOVIR HCL TAB 450 MG (BASE EQUIVALENT) CHOLECALCIFEROL TAB 10 MCG (400 UNIT) ACETAMINOPHEN TAB 325 MG

Appendix F9 205 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs DOCUSATE SODIUM CAP 250 MG ATENOLOL TAB 50 MG AZITHROMYCIN TAB 250 MG LORLATINIB TAB 25 MG Y FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.5-25-1 MG BUDESONIDE NASAL SUSP 32 MCG/ACT *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS LIQUID** ISOSORBIDE DINITRATE TAB 30 MG NAPROXEN TAB 250 MG *ADHESIVE BANDAGES*** FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 30-600 MG *MULTIPLE VITAMINS W/ MINERALS TAB** MELATONIN SL TAB 10 MG *BIOFLAVONOID PRODUCTS CHEW TAB** BALSALAZIDE DISODIUM CAP 750 MG CONDOMS LATEX LUBRICATED POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG) *BIOFLAVONOID PRODUCTS CAP** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") PANCRELIPASE (LIP-PROT-AMYL) DR CAP 24000-76000-120000 UNIT GUAIFENESIN LIQUID 100 MG/5ML CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM *ADHESIVE BANDAGES*** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 250 MG-125 UNIT *MULTIPLE VITAMINS W/ MINERALS TAB** LISINOPRIL TAB 20 MG *VITAMINS W/ LIPOTROPICS TAB** SECUKINUMAB SUBCUTANEOUS AUTO-INJ 150 MG/ML (300 MG DOSE) Y SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)

Appendix F9 206 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% *MULTIPLE VITAMIN TAB** *ADHESIVE BANDAGES*** MICONAZOLE NITRATE POWDER 2% LEVONORGESTREL TAB 1.5 MG *MULTIPLE VITAMINS W/ MINERALS TAB** HYDROCORTISONE CREAM 1% CARBOXYMETHYLCELL-GLYC-POLYSORB 80 (PF) OPHTH SOL 0.5-1-0.5% PERMETHRIN LOTION 1% *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) *VITAMIN MIXTURE LIQ** DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 200 MCG/0.4ML Y *MULTIPLE VITAMINS W/ MINERALS TAB** ASPIRIN TAB DELAYED RELEASE 500 MG SODIUM FLUORIDE CREAM 1.1% *MULTIPLE VITAMINS W/ MINERALS TAB** *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** *LANCETS*** RITONAVIR POWDER PACKET 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** FLUTICASONE FUROATE AEROSOL POWDER BREATH ACTIV 100 MCG/ACT DIPHENHYDRAMINE HCL TAB 25 MG FLUTICASONE FUROATE AEROSOL POWDER BREATH ACTIV 100 MCG/ACT CHOLECALCIFEROL TAB 25 MCG (1000 UNIT) CALCITRIOL CAP 0.25 MCG SECUKINUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 150 MG/ML Y THIAMINE HCL TAB 100 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 207 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs QUINAPRIL HCL TAB 40 MG CHOLECALCIFEROL CAP 125 MCG (5000 UNIT) PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO 0.33-4% MICONAZOLE NITRATE CREAM 2% SOMATROPIN INJ 10 MG/1.5ML Y *PEDIATRIC MULTIPLE VITAMIN LIQ** BISACODYL SUPPOS 10 MG *SPECIALITY VITAMIN PRODUCT TAB** *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG SENNOSIDES CHEW TAB 15 MG MEMANTINE HCL TAB 28 X 5 MG & 21 X 10 MG TITRATION PACK *MULTIPLE VITAMINS W/ MINERALS TAB** SENNOSIDES TAB 25 MG POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ *MULTIPLE VITAMINS W/ MINERALS TAB** BETHANECHOL CHLORIDE TAB 25 MG *LACTOBACILLUS CAP** CALCIUM CARBONATE TAB 600 MG PREDNISONE TAB THERAPY PACK 5 MG (48) THEOPHYLLINE TAB ER 12HR 450 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *LANCETS*** LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG METOLAZONE TAB 2.5 MG NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1% SIPONIMOD FUMARATE TAB 2 MG (BASE EQUIV) Y ACETAMINOPHEN CHEW TAB 80 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 208 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs PREDNISONE TAB 5 MG PHENYTOIN SODIUM EXTENDED CAP 300 MG NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG PREDNISONE TAB THERAPY PACK 5 MG (21) AZITHROMYCIN TAB 600 MG *MULTIPLE VITAMIN TAB** ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE CHEW TAB 160-105 MG BISMUTH SUBSALICYLATE CHEW TAB 262 MG LIDOCAINE-PRILOCAINE CREAM 2.5-2.5% DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 60-1200 MG *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.5 MG/ML*** *B-COMPLEX W/ C & FOLIC ACID TAB*** LACTIC ACID (AMMONIUM LACTATE) LOTION 12% *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** BISACODYL TAB DELAYED RELEASE 5 MG NAPROXEN SODIUM TAB 220 MG FERROUS SULFATE TAB 27 MG (ELEMENTAL FE) LORATADINE TAB 10 MG LORATADINE TAB 10 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *LACTOBACILLUS CAP** SECUKINUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML Y *LANCETS*** HYDROCORTISONE CREAM 1% SECUKINUMAB SUBCUTANEOUS PREF SYR 150 MG/ML (300 MG DOSE) Y SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) ACETAMINOPHEN DISINTEGRATING TAB 80 MG HYDROCORTISONE BUTYRATE SOLN 0.1% GUAIFENESIN TAB 200 MG DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG CAPTOPRIL TAB 100 MG

Appendix F9 209 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs OYSTER SHELL CALCIUM TAB 500 MG OMEPRAZOLE CAP DELAYED RELEASE 40 MG INSULIN PEN NEEDLE 32 G X 4 MM (1/6" OR 5/32") CAPECITABINE TAB 150 MG Y OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG Y FEXOFENADINE HCL TAB 180 MG ACETAMINOPHEN SUPPOS 80 MG SENNOSIDES CHEW TAB 15 MG *B-COMPLEX W/ C & E + ZN TAB*** FLUOCINONIDE SOLN 0.05% *BIOFLAVONOID PRODUCTS TAB** EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 60 MG/0.4ML (150 MG/ML) Y *MULTIPLE VITAMINS W/ MINERALS CAP** CALCIUM CARBONATE-CHOLECALCIFEROL TAB 250 MG-125 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL TAB 250 MG-125 UNIT *VITAMINS W/ LIPOTROPICS TAB** IBUPROFEN SUSP 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS CAP** DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 30-600 MG GUAIFENESIN TAB ER 12HR 1200 MG *MULTIPLE VITAMINS W/ MINERALS TAB** MECLIZINE HCL TAB 25 MG *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CAP** DOLUTEGRAVIR SODIUM TAB 50 MG (BASE EQUIV) LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG ALUMINUM HYDROXIDE-MAGNESIUM TRISILICATE CHEW TAB 80-14.2 MG CHLORHEXIDINE GLUCONATE LIQUID 4% *B-COMPLEX W/ C & E + ZN TAB*** ETHAMBUTOL HCL TAB 400 MG *LANCETS*** LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)

Appendix F9 210 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CHLORPHENIRAMINE MALEATE TAB 4 MG *MULTIPLE VITAMINS W/ MINERALS TAB** DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML HYDROXYCHLOROQUINE SULFATE TAB 200 MG *MULTIPLE VITAMINS W/ CALCIUM TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS TAB** CHOLECALCIFEROL CAP 25 MCG (1000 UNIT) *MULTIPLE VITAMINS W/ MINERALS TAB** PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-2 MG ISOTRETINOIN CAP 30 MG Y ACETAMINOPHEN TAB 500 MG VERAPAMIL HCL TAB ER 120 MG FLUTICASONE PROPIONATE HFA INHAL AER 110 MCG/ACT (125/VALVE) LORATADINE SYRUP 5 MG/5ML LENALIDOMIDE CAP 15 MG Y GUAIFENESIN-CODEINE SOLN 100-6.3 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB ER** TOLNAFTATE AEROSOL POW 1% *PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB 90 &DHA CAP 300MG PAK* *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** *RESPIRATORY THERAPY SUPPLIES - MISC** FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) IDELALISIB TAB 100 MG Y SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML PHENYTOIN SUSP 125 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML LENALIDOMIDE CAPS 2.5 MG Y INSULIN NPH ISOPHANE & REGULAR HUMAN INJ 100 UNIT/ML (70-30) *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** ACETAMINOPHEN SUPPOS 120 MG CHLORPHENIRAMINE MALEATE TAB ER 12 MG CALCIUM CARBONATE (ANTACID) CHEW TAB 1000 MG

Appendix F9 211 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *BIOFLAVONOID PRODUCTS TAB ER** URSODIOL TAB 500 MG BISMUTH SUBSALICYLATE CHEW TAB 262 MG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) TRANDOLAPRIL TAB 4 MG ONDANSETRON HCL TAB 24 MG FLUTICASONE PROPIONATE HFA INHAL AERO 44 MCG/ACT (50/VALVE) CHOLECALCIFEROL TAB 50 MCG (2000 UNIT) EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000) ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** LEVONORGESTREL RELEASING IUD 19.5 MCG/DAY (52 MG TOTAL) LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT) Y METHADONE HCL TAB 10 MG Y *LANCETS*** *LANCETS*** ACETAMINOPHEN SOLN 160 MG/5ML ACETAMINOPHEN DISINTEGRATING TAB 80 MG FLURBIPROFEN TAB 50 MG CETIRIZINE HCL CHEW TAB 5 MG ASPIRIN TAB DELAYED RELEASE 325 MG *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *LANCETS*** *SPECIALITY VITAMIN PRODUCT CAP** EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 30 MG/ML Y DEXTROMETHORPHAN-GUAIFENESIN TAB ER 12HR 30-600 MG *LANCETS*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *LANCETS*** DOCUSATE SODIUM LIQUID 150 MG/15ML ATENOLOL & CHLORTHALIDONE TAB 100-25 MG SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML Y *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER***

Appendix F9 212 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *OMEGA-3 FATTY ACIDS CAP 1400 MG** ATOVAQUONE-PROGUANIL HCL TAB 250-100 MG *MULTIPLE VITAMINS W/ MINERALS TAB** INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16" NATAMYCIN OPHTH SUSP 5% *MULTIPLE VITAMINS W/ MINERALS TAB** METHYLPREDNISOLONE TAB 4 MG ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV) Y *MULTIPLE VITAMINS W/ MINERALS TAB** METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21) TRETINOIN CREAM 0.05% Y *LANCETS*** DEXTRAN 70-HYPROMELLOSE OPHTH SOLN 0.1-0.3% ALENDRONATE SODIUM TAB 10 MG NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1% *MULTIPLE VITAMINS W/ MINERALS TAB** FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE) HYPROMELLOSE OPHTH SOLN 0.3% *LANCETS*** SALINE NASAL SPRAY 0.65% ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML ACETAMINOPHEN SUPPOS 120 MG SULFADIAZINE TAB 500 MG LEVOTHYROXINE SODIUM TAB 88 MCG CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) FERROUS SULFATE TAB ER 142 MG (45 MG FE EQUIVALENT) CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2" DIDANOSINE DELAYED RELEASE CAPSULE 200 MG AMPICILLIN CAP 500 MG HYDROCORTISONE PERIANAL CREAM 1% ALUMINUM HYDROXIDE-MAGNESIUM TRISILICATE CHEW TAB 80-20 MG *MULTIPLE VITAMINS W/ MINERALS TAB**

Appendix F9 213 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs ASPIRIN TAB DELAYED RELEASE 325 MG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG EVEROLIMUS TAB 10 MG Y DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16" *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** LEVOTHYROXINE SODIUM TAB 150 MCG ENOXAPARIN SODIUM INJ 40 MG/0.4ML *ADHESIVE BANDAGES*** LANSOPRAZOLE CAP DELAYED RELEASE 15 MG *B-COMPLEX W/BIOTIN & FOLIC ACID TAB ER*** GUAIFENESIN TAB ER 12HR 1200 MG *MULTIPLE VITAMINS W/ IRON TAB** CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT ANTIHEMOPHILIC FACTOR RECOM PEGYLATED-AUCL FOR INJ 3000 UNIT Y *MULTIPLE VITAMINS W/ MINERALS PACK** CONDOMS LATEX NON-LUBRICATED ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML DIPHENHYDRAMINE HCL CAP 25 MG POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% *BACITRACIN-POLYMYXIN B OINT*** PYRANTEL PAMOATE TAB 180 MG *MULTIPLE VITAMINS W/ IRON TAB** *BIOFLAVONOID PRODUCTS TAB ER** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML *BIOFLAVONOID PRODUCTS TAB** AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG *LANCETS*** *ADHESIVE BANDAGES*** *LANCETS*** *OMEGA-3 FATTY ACIDS CAP 300 MG** *LANCETS***

Appendix F9 214 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *MULTIPLE VITAMINS W/ MINERALS CAP** LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG *LANCETS*** CIMETIDINE TAB 200 MG *RESPIRATORY THERAPY SUPPLIES - MISC** *LANCETS*** PSEUDOEPHEDRINE-GUAIFENESIN TAB ER 12HR 60-600 MG *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *OMEGA-3 FATTY ACIDS CAP 300 MG** LIDOCAINE PATCH 4% *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** POLYETHYLENE GLYCOL-PROPYLENE GLYCOL OPHTH SOLN 0.4-0.3% *MULTIPLE VITAMINS W/ MINERALS TAB** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** GLIMEPIRIDE TAB 2 MG ASPIRIN TAB 500 MG CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLN 0.5% SELENIUM SULFIDE LOTION 1% *LANCETS*** *ADHESIVE BANDAGES*** RIVAROXABAN TAB 15 MG PROPRANOLOL HCL CAP ER 24HR 120 MG *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *RESPIRATORY THERAPY SUPPLIES - MISC** SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG GUAIFENESIN SYRUP 100 MG/5ML ACETAMINOPHEN TAB 500 MG GUAIFENESIN LIQUID 100 MG/5ML *ADHESIVE BANDAGES*** *ADHESIVE BANDAGES*** PYRIDOSTIGMINE BROMIDE TAB ER 180 MG

Appendix F9 215 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *LANCETS*** *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML *LACTOBACILLUS - PACKET** *ADHESIVE BANDAGES*** *VITAMINS W/ LIPOTROPICS TAB** SALINE NASAL SPRAY 0.65% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML *ADHESIVE BANDAGES*** MICONAZOLE NITRATE CREAM 2% *MULTIPLE VITAMIN TAB** OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML) Y METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG DEXAMETHASONE ELIXIR 0.5 MG/5ML DILTIAZEM HCL CAP ER 12HR 90 MG *LANCETS*** BETAMETHASONE DIPROPIONATE LOTION 0.05% VALSARTAN TAB 160 MG TROSPIUM CHLORIDE TAB 20 MG LIDOCAINE PATCH 4% NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG OXYCODONE HCL TAB 30 MG Y HYDROCORTISONE CREAM 1% *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *MULTIPLE VITAMINS W/ MINERALS TAB** HYDROCORTISONE CREAM 2.5% GUAIFENESIN TAB ER 12HR 600 MG CYCLOSPORINE ORAL SOLN 100 MG/ML *LANCETS*** LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV)

Appendix F9 216 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs *COD LIVER OIL*** *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** *WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT*** *ADHESIVE BANDAGES*** SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG BOSENTAN TAB 62.5 MG Y CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** LENVATINIB CAP THERAPY PACK 2 X 4 MG (8 MG DAILY DOSE) Y *LACTOBACILLUS CAP** CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1% BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) GUAIFENESIN LIQUID 100 MG/5ML DOXERCALCIFEROL CAP 0.5 MCG *MULTIPLE VITAMINS W/ MINERALS TAB** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** VALGANCICLOVIR HCL FOR SOLN 50 MG/ML (BASE EQUIV) *ADHESIVE BANDAGES*** ISONIAZID SYRUP 50 MG/5ML LEVOTHYROXINE SODIUM TAB 88 MCG *B-COMPLEX W/ FOLIC ACID CAP** ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG DARBEPOETIN ALFA SOLN INJ 25 MCG/ML Y *DIAPER RASH PRODUCTS - OINTMENT** EVEROLIMUS TAB 2.5 MG Y *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** CARBAMIDE PEROXIDE 6.5% OTIC SOLN NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG CROSS-LINKED HYALURONATE GEL PREFILLED SYRINGE 30 MG/3ML Y

Appendix F9 217 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *MASKS*** ULIPRISTAL ACETATE TAB 30 MG DOCUSATE SODIUM CAP 250 MG CALCIUM CARBONATE TAB 600 MG THIAMINE HCL TAB 100 MG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG *MASKS*** INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *MULTIPLE VITAMINS W/ MINERALS TAB** IBUPROFEN CAP 200 MG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML ACETAMINOPHEN TAB ER 650 MG ISONIAZID TAB 100 MG *ALCOHOL SWABS*** FULVESTRANT INJ 250 MG/5ML Y *VITAMINS W/ LIPOTROPICS TAB** NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG PHENYTOIN SUSP 125 MG/5ML ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG CLOTRIMAZOLE SOLN 1% FEXOFENADINE HCL TAB 180 MG CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-200 UNIT SODIUM FLUORIDE PASTE 1.1% DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML *ALCOHOL SWABS*** DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG *MULTIPLE VITAMINS W/ MINERALS CHEW TAB**

Appendix F9 218 Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to NQTLs, by Delivery System

Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Prescription Drug Formulary Med/Surg Drugs Med/Surg Drugs BENZOYL PEROXIDE GEL 2.5% GUAIFENESIN LIQUID 100 MG/5ML *MULTIPLE VITAMINS W/ MINERALS TAB** *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** CHLORZOXAZONE TAB 500 MG *LACTOBACILLUS CAP** CHOLECALCIFEROL CAP 250 MCG (10000 UNIT) *LACTOBACILLUS TAB** ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG HYDROCORTISONE CREAM 1% LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG CARISOPRODOL TAB 350 MG CLINDAMYCIN PHOSPHATE SOLN 1% GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML

Appendix F9 219