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