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.