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

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Appendix F9. University of Maryland Health Partners (UMHP) Prescription Drugs Subject to Nqtls, by Delivery System 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-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG TAMOXIFEN 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 DIPHENHYDRAMINE 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 ESTRADIOL 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*** LORATADINE 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** MISOPROSTOL 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 ALCOHOL 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 ATENOLOL TAB 100 MG FEXOFENADINE-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.
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