165
Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System Appendix F5 1 Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTL Med/Surg Drugs Med/Surg Drugs 12 HOUR NASAL RELIEF SPRAY ABACAVIR-LAMIVUDINE 600-300 MG ABREVA 10% CREAM 1ST TIER COMFORTOUCH 28G LANCT ABACAVIR-LAMIVUDINE-ZIDOV TAB ACETAMINOP-CODEINE 120-12 MG/5 1ST TIER COMFORTOUCH 30G LANCT ADCIRCA 20 MG TABLET ACETAMINOPHEN-COD #2 TABLET 1ST TIER UNIFINE PENTP 5MM 31G ADEMPAS 0.5 MG TABLET ACETAMINOPHEN-COD #3 TABLET 1ST TIER UNIFINE PNTIP 4MM 32G ADEMPAS 1 MG TABLET ACETAMINOPHEN-COD #4 TABLET 1ST TIER UNIFINE PNTIP 6MM 31G ADEMPAS 1.5 MG TABLET ACID CONTROLLER 20 MG TABLET 1ST TIER UNIFINE PNTIP 8MM 31G ADEMPAS 2 MG TABLET ACID REDUCER 20 MG TABLET 1ST TIER UNIFINE PNTP 12MM 29G ADEMPAS 2.5 MG TABLET ACIPHEX SPRINKLE DR 10 MG CAP 1ST TIER UNIFINE PNTP 29GX1/2'' ADMELOG SOLOSTAR 100 UNIT/ML ACIPHEX SPRINKLE DR 5 MG CAP 1ST TIER UNIFINE PNTP 31GX1/4'' AMBRISENTAN 10 MG TABLET ACYCLOVIR 200 MG CAPSULE 1ST TIER UNIFINE PNTP 31GX3/16 AMBRISENTAN 5 MG TABLET ACYCLOVIR 200 MG/5 ML SUSP 1ST TIER UNIFINE PNTP 31GX5/16 APTIVUS 100 MG/ML SOLUTION ACYCLOVIR 400 MG TABLET 1ST TIER UNIFINE PNTP 32GX5/32 APTIVUS 250 MG CAPSULE ACYCLOVIR 5% OINTMENT 5-AMINOSALICYLIC ACID POWD ATRIPLA TABLET ACYCLOVIR 800 MG TABLET 5-AMINOSALICYLIC ACID POWDER AUBAGIO 14 MG TABLET ADAPALENE 0.1% CREAM 8 HOUR ACETAMINOPHEN ER 650 MG AUBAGIO 7 MG TABLET ADAPALENE 0.1% GEL A THRU Z ADVANCED FORMULA TAB BENZNIDAZOLE 100 MG TABLET ALA-CORT 1% CREAM A THRU Z MEN'S ULTIMATE TABLET BUDESONIDE 0.25 MG/2 ML SUSP ALAWAY 0.025% EYE DROPS A THRU Z SELECT 50 PLUS TABLET BUDESONIDE 0.5 MG/2 ML SUSP ALBUTEROL HFA 90 MCG INHALER A THRU Z SELECT MEN 50+ TABLET BUDESONIDE 1 MG/2 ML INH SUSP ALBUTEROL SUL 0.63 MG/3 ML SOL A THRU Z SELECT MULTIVIT TAB CEFUROXIME SOD 1.5 GM VIAL ALBUTEROL SUL 1.25 MG/3 ML SOL A THRU Z SELECT TABLET CEFUROXIME SOD 750 MG VIAL ALBUTEROL SUL 2.5 MG/3 ML SOLN A THRU Z SELECT WOMEN'S TABLET CELLCEPT 500 MG VIAL ALCLOMETASONE DIPR 0.05% OINT ABACAVIR 20 MG/ML SOLUTION CHLOROQUINE PH 250 MG TABLET ALCLOMETASONE DIPRO 0.05% CRM ABACAVIR 300 MG TABLET CHLOROQUINE PH 500 MG TABLET ALLERGY RELIEF 50 MCG SPRAY ABACAVIR-LAMIVUDINE 600-300 MG CLONIDINE HCL ER 0.1 MG TABLET ALLOPURINOL 100 MG TABLET ABACAVIR-LAMIVUDINE-ZIDOV TAB COMBIVIR TABLET ALLOPURINOL 300 MG TABLET ABC PLUS TABLET COMPLERA TABLET ALOGLIPTIN 12.5 MG TABLET ABREVA 10% CREAM CRESTOR 10 MG TABLET ALOGLIPTIN 25 MG TABLET ACARBOSE 100 MG TABLET CRESTOR 20 MG TABLET ALOGLIPTIN 6.25 MG TABLET ACARBOSE 25 MG TABLET CRESTOR 40 MG TABLET ALOGLIPTIN-METFORMIN 12.5-1000 ACARBOSE 50 MG TABLET CRESTOR 5 MG TABLET ALOGLIPTIN-METFORMIN 12.5-500 ACCU-CHEK FASTCLIX LANCET DRUM CRIXIVAN 200 MG CAPSULE AMCINONIDE 0.1% CREAM

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Page 1: Appendix F5. Maryland Physicians Care (MPC)

Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System

Appendix F5 1

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

12 HOUR NASAL RELIEF SPRAY ABACAVIR-LAMIVUDINE 600-300 MG ABREVA 10% CREAM

1ST TIER COMFORTOUCH 28G LANCT ABACAVIR-LAMIVUDINE-ZIDOV TAB ACETAMINOP-CODEINE 120-12 MG/5

1ST TIER COMFORTOUCH 30G LANCT ADCIRCA 20 MG TABLET ACETAMINOPHEN-COD #2 TABLET

1ST TIER UNIFINE PENTP 5MM 31G ADEMPAS 0.5 MG TABLET ACETAMINOPHEN-COD #3 TABLET

1ST TIER UNIFINE PNTIP 4MM 32G ADEMPAS 1 MG TABLET ACETAMINOPHEN-COD #4 TABLET

1ST TIER UNIFINE PNTIP 6MM 31G ADEMPAS 1.5 MG TABLET ACID CONTROLLER 20 MG TABLET

1ST TIER UNIFINE PNTIP 8MM 31G ADEMPAS 2 MG TABLET ACID REDUCER 20 MG TABLET

1ST TIER UNIFINE PNTP 12MM 29G ADEMPAS 2.5 MG TABLET ACIPHEX SPRINKLE DR 10 MG CAP

1ST TIER UNIFINE PNTP 29GX1/2'' ADMELOG SOLOSTAR 100 UNIT/ML ACIPHEX SPRINKLE DR 5 MG CAP

1ST TIER UNIFINE PNTP 31GX1/4'' AMBRISENTAN 10 MG TABLET ACYCLOVIR 200 MG CAPSULE

1ST TIER UNIFINE PNTP 31GX3/16 AMBRISENTAN 5 MG TABLET ACYCLOVIR 200 MG/5 ML SUSP

1ST TIER UNIFINE PNTP 31GX5/16 APTIVUS 100 MG/ML SOLUTION ACYCLOVIR 400 MG TABLET

1ST TIER UNIFINE PNTP 32GX5/32 APTIVUS 250 MG CAPSULE ACYCLOVIR 5% OINTMENT

5-AMINOSALICYLIC ACID POWD ATRIPLA TABLET ACYCLOVIR 800 MG TABLET

5-AMINOSALICYLIC ACID POWDER AUBAGIO 14 MG TABLET ADAPALENE 0.1% CREAM

8 HOUR ACETAMINOPHEN ER 650 MG AUBAGIO 7 MG TABLET ADAPALENE 0.1% GEL

A THRU Z ADVANCED FORMULA TAB BENZNIDAZOLE 100 MG TABLET ALA-CORT 1% CREAM

A THRU Z MEN'S ULTIMATE TABLET BUDESONIDE 0.25 MG/2 ML SUSP ALAWAY 0.025% EYE DROPS

A THRU Z SELECT 50 PLUS TABLET BUDESONIDE 0.5 MG/2 ML SUSP ALBUTEROL HFA 90 MCG INHALER

A THRU Z SELECT MEN 50+ TABLET BUDESONIDE 1 MG/2 ML INH SUSP ALBUTEROL SUL 0.63 MG/3 ML SOL

A THRU Z SELECT MULTIVIT TAB CEFUROXIME SOD 1.5 GM VIAL ALBUTEROL SUL 1.25 MG/3 ML SOL

A THRU Z SELECT TABLET CEFUROXIME SOD 750 MG VIAL ALBUTEROL SUL 2.5 MG/3 ML SOLN

A THRU Z SELECT WOMEN'S TABLET CELLCEPT 500 MG VIAL ALCLOMETASONE DIPR 0.05% OINT

ABACAVIR 20 MG/ML SOLUTION CHLOROQUINE PH 250 MG TABLET ALCLOMETASONE DIPRO 0.05% CRM

ABACAVIR 300 MG TABLET CHLOROQUINE PH 500 MG TABLET ALLERGY RELIEF 50 MCG SPRAY

ABACAVIR-LAMIVUDINE 600-300 MG CLONIDINE HCL ER 0.1 MG TABLET ALLOPURINOL 100 MG TABLET

ABACAVIR-LAMIVUDINE-ZIDOV TAB COMBIVIR TABLET ALLOPURINOL 300 MG TABLET

ABC PLUS TABLET COMPLERA TABLET ALOGLIPTIN 12.5 MG TABLET

ABREVA 10% CREAM CRESTOR 10 MG TABLET ALOGLIPTIN 25 MG TABLET

ACARBOSE 100 MG TABLET CRESTOR 20 MG TABLET ALOGLIPTIN 6.25 MG TABLET

ACARBOSE 25 MG TABLET CRESTOR 40 MG TABLET ALOGLIPTIN-METFORMIN 12.5-1000

ACARBOSE 50 MG TABLET CRESTOR 5 MG TABLET ALOGLIPTIN-METFORMIN 12.5-500

ACCU-CHEK FASTCLIX LANCET DRUM CRIXIVAN 200 MG CAPSULE AMCINONIDE 0.1% CREAM

Page 2: Appendix F5. Maryland Physicians Care (MPC)

Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System

Appendix F5 2

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ACCU-CHEK FASTCLIX LANCING DEV CRIXIVAN 400 MG CAPSULE AMCINONIDE 0.1% LOTION

ACCU-CHEK MULTICLIX LANCET KIT CRYSVITA 10 MG/ML VIAL ANASTROZOLE 1 MG TABLET

ACCU-CHEK MULTICLIX LANCETS CRYSVITA 20 MG/ML VIAL ANORO ELLIPTA 62.5-25 MCG INH

ACCU-CHEK SAFE-T-PRO 23G LANCT CRYSVITA 30 MG/ML VIAL ASA-BUTALB-CAFF-COD #3 CAPSULE

ACCU-CHEK SAFE-T-PRO PLUS 23G DARAPRIM 25 MG TABLET ASCOMP WITH CODEINE CAPSULE

ACCU-CHEK SOFTCLIX LANCET KIT DELSTRIGO 100-300-300 MG TAB ATORVASTATIN 10 MG TABLET

ACCU-CHEK SOFTCLIX LANCETS DESCOVY 200-25 MG TABLET ATORVASTATIN 20 MG TABLET

ACCUTREND GLUCOSE CONTROL DIDANOSINE DR 250 MG CAPSULE ATORVASTATIN 40 MG TABLET

ACEBUTOLOL 200 MG CAPSULE DIDANOSINE DR 400 MG CAPSULE ATORVASTATIN 80 MG TABLET

ACEBUTOLOL 400 MG CAPSULE DOPTELET (10 TAB PK) 20 MG TAB AVITA 0.025% GEL

ACEBUTOLOL HCL POWDER DOPTELET (15 TAB PK) 20 MG TAB AZELASTINE HCL 0.05% DROPS

ACETAMINOP-CODEINE 120-12 MG/5 DOPTELET (30 TAB PK) 20 MG TAB AZOPT 1% EYE DROPS

ACETAMINOPHEN 160 MG/5 ML ELIX DOVATO 50-300 MG TABLET BETAMETHASONE DP 0.05% CRM

ACETAMINOPHEN 160 MG/5 ML LIQ EDURANT 25 MG TABLET BETAMETHASONE DP 0.05% LOT

ACETAMINOPHEN 160 MG/5 ML SOL EFAVIRENZ 200 MG CAPSULE BETAMETHASONE DP 0.05% OINT

ACETAMINOPHEN 325 MG GELCAP EFAVIRENZ 50 MG CAPSULE BETAMETHASONE DP AUG 0.05% CRM

ACETAMINOPHEN 325 MG TABLET EFAVIRENZ 600 MG TABLET BETAMETHASONE DP AUG 0.05% GEL

ACETAMINOPHEN 500 MG CAPLET ELIQUIS 2.5 MG TABLET BETAMETHASONE DP AUG 0.05% LOT

ACETAMINOPHEN 500 MG GELCAP ELIQUIS 5 MG TABLET BETAMETHASONE DP AUG 0.05% OIN

ACETAMINOPHEN 500 MG TABLET EMTRIVA 10 MG/ML SOLUTION BETAMETHASONE VA 0.1% CREAM

ACETAMINOPHEN 80 MG RAPID TAB EMTRIVA 200 MG CAPSULE BETAMETHASONE VA 0.1% LOTION

ACETAMINOPHEN ER 650 MG CAPLET ENTRESTO 24 MG-26 MG TABLET BETAMETHASONE VALER 0.1% OINTM

ACETAMINOPHEN ER 650 MG TABLET ENTRESTO 49 MG-51 MG TABLET BICALUTAMIDE 50 MG TABLET

ACETAMINOPHEN-COD #2 TABLET ENTRESTO 97 MG-103 MG TABLET BOSULIF 100 MG TABLET

ACETAMINOPHEN-COD #3 TABLET EPZICOM TABLET BOSULIF 500 MG TABLET

ACETAMINOPHEN-COD #4 TABLET EVOTAZ 300 MG-150 MG TABLET BUDESONIDE 32 MCG NASAL SPRAY

ACETAZOLAMIDE 125 MG TABLET FLOVENT HFA 110 MCG INHALER BUDESONIDE ER 9 MG TABLET

ACETAZOLAMIDE 250 MG TABLET FLOVENT HFA 220 MCG INHALER BUTALB-CAFF-ACETAMINOPH-CODEIN

ACETAZOLAMIDE ER 500 MG CAP FLOVENT HFA 44 MCG INHALER BUTALBITAL COMP-CODEINE #3 CAP

ACETIC ACID 2% EAR SOLUTION FLUTICASONE-SALMETEROL 100-50 BUTORPHANOL 10 MG/ML SPRAY

ACETYL SALICYLIC ACID POWDER FLUTICASONE-SALMETEROL 250-50 CALCITRIOL 0.25 MCG CAPSULE

ACETYLCYSTEINE 10% VIAL FLUTICASONE-SALMETEROL 500-50 CALCITRIOL 0.5 MCG CAPSULE

ACETYLCYSTEINE 20% VIAL FOSAMPRENAVIR 700 MG TABLET CALCITRIOL 1 MCG/ML SOLUTION

Page 3: Appendix F5. Maryland Physicians Care (MPC)

Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System

Appendix F5 3

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ACETYLCYSTEINE POWDER GENVOYA TABLET CAPECITABINE 150 MG TABLET

ACID CONTROLLER 20 MG TABLET GILENYA 0.5 MG CAPSULE CAPECITABINE 500 MG TABLET

ACID REDUCER 20 MG TABLET GRANISETRON HCL 1 MG TABLET CELECOXIB 100 MG CAPSULE

ACIDOPHILUS LACTOBACILLUS POWD GUANFACINE HCL ER 1 MG TABLET CELECOXIB 200 MG CAPSULE

ACIPHEX SPRINKLE DR 10 MG CAP GUANFACINE HCL ER 2 MG TABLET CELECOXIB 400 MG CAPSULE

ACIPHEX SPRINKLE DR 5 MG CAP GUANFACINE HCL ER 3 MG TABLET CELECOXIB 50 MG CAPSULE

ACNE MEDICATION 5% GEL GUANFACINE HCL ER 4 MG TABLET CHILDREN IBUPROFEN 100 MG/5 ML

ACNE MEDICATION 5% LOTION HYDROXYCHLOROQUINE 200 MG TAB CHILD'S ALAWAY 0.025% EYE DROP

ACTI-LANCE LITE 28G LANCETS INSULIN LISPRO 100 UNIT/ML PEN CIMETIDINE 200 MG TABLET

ACTI-LANCE SPECIAL 17G LANCETS INTELENCE 100 MG TABLET CIMETIDINE 300 MG TABLET

ACTI-LANCE UNIVERS 23G LANCETS INTELENCE 200 MG TABLET CIMETIDINE 300 MG/5 ML SOLN

ACYCLOVIR 200 MG CAPSULE INTELENCE 25 MG TABLET CIMETIDINE 400 MG TABLET

ACYCLOVIR 200 MG/5 ML SUSP INVIRASE 500 MG TABLET CIMETIDINE 800 MG TABLET

ACYCLOVIR 400 MG TABLET ITRACONAZOLE 10 MG/ML SOLUTION CLOBETASOL 0.05% CREAM

ACYCLOVIR 5% OINTMENT ITRACONAZOLE 100 MG CAPSULE CLOBETASOL 0.05% GEL

ACYCLOVIR 800 MG TABLET JULUCA 50-25 MG TABLET CLOBETASOL 0.05% OINTMENT

ADACEL TDAP VIAL KALETRA 100-25 MG TABLET CLOBETASOL 0.05% SHAMPOO

ADAPALENE 0.1% CREAM KALETRA 200-50 MG TABLET CLOBETASOL 0.05% SOLUTION

ADAPALENE 0.1% GEL KALETRA 80 MG-20 MG/ML SOLN CLOBETASOL 0.05% TOPICAL LOTN

ADCIRCA 20 MG TABLET LAMIVUDINE-ZIDOVUDINE TABLET CLOBETASOL EMOLLIENT 0.05% CRM

ADEFOVIR DIPIVOXIL 10 MG TAB LANSOPRAZOLE ODT 15 MG TABLET CLOBETASOL PROP 0.05% FOAM

ADEMPAS 0.5 MG TABLET LANSOPRAZOLE ODT 30 MG TABLET CLODAN 0.05% SHAMPOO

ADEMPAS 1 MG TABLET LETAIRIS 10 MG TABLET CLONIDINE HCL ER 0.1 MG TABLET

ADEMPAS 1.5 MG TABLET LETAIRIS 5 MG TABLET CODEINE SULFATE 15 MG TABLET

ADEMPAS 2 MG TABLET LEXIVA 50 MG/ML SUSPENSION CODEINE SULFATE 30 MG TABLET

ADEMPAS 2.5 MG TABLET LEXIVA 700 MG TABLET CODEINE SULFATE 60 MG TABLET

ADJUSTABLE LANCING DEVICE LIDOCAINE 5% PATCH COMETRIQ 100 MG DAILY-DOSE PK

ADLT WAL-TUSSIN COUGH-COLD CF LOKELMA 10 GRAM POWDER PACKET COMETRIQ 140 MG DAILY-DOSE PK

ADMELOG 100 UNIT/ML VIAL LOKELMA 5 GRAM POWDER PACKET COMETRIQ 60 MG DAILY-DOSE PACK

ADMELOG SOLOSTAR 100 UNIT/ML LOPINAVIR-RITONAVIR 80-20MG/ML CORTISONE 25 MG TABLET

ADULT WAL-TUSSIN DM SYRUP MIACALCIN 400 UNIT/2 ML VIAL CRESTOR 10 MG TABLET

ADULT WAL-TUSSIN LIQUID MOVANTIK 12.5 MG TABLET CRESTOR 20 MG TABLET

ADULTS 50 PLUS DAILY FORMULA MOVANTIK 25 MG TABLET CRESTOR 40 MG TABLET

Page 4: Appendix F5. Maryland Physicians Care (MPC)

Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System

Appendix F5 4

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ADVANCED LANCING DEVICE MULTAQ 400 MG TABLET CRESTOR 5 MG TABLET

ADVANCED TRAVEL 28G LANCETS MYCOPHENOLATE 500 MG VIAL CVS ACID CONTROLLER 20 MG TAB

ADVANCED TRAVEL 30G LANCETS OCREVUS 300 MG/10 ML VIAL CVS ALLERGY 0.025% EYE DROPS

ADVOCATE 26G LANCETS ODEFSEY TABLET CVS BUDESONIDE 32 MCG SPRAY

ADVOCATE 30G LANCETS ONDANSETRON HCL 24 MG TABLET CVS CHLD IBUPROFEN 100 MG/5 ML

ADVOCATE INS 0.3 ML 30GX5/16'' PALYNZIQ 10 MG/0.5 ML SYRINGE CVS CIMETIDINE 200 MG TABLET

ADVOCATE INS 0.3 ML 31GX5/16'' PALYNZIQ 2.5 MG/0.5 ML SYRINGE CVS EYE ITCH RELIEF 0.025% DRP

ADVOCATE INS 0.5 ML 30GX5/16'' PALYNZIQ 20 MG/ML SYRINGE CVS FLUTICASONE PROP 50 MCG

ADVOCATE INS 0.5 ML 31GX5/16'' PIFELTRO 100 MG TABLET CVS IBUPROFEN 200 MG CAPLET

ADVOCATE INS 1 ML 31GX5/16'' PLAQUENIL 200 MG TABLET CVS IBUPROFEN 200 MG TABLET

ADVOCATE INS SYR 0.3ML 29GX1/2 PODOCON-25 LIQUID CVS LANSOPRAZOLE DR 15 MG CAP

ADVOCATE INS SYR 0.5ML 29GX1/2 POTELIGEO 20 MG/5 ML VIAL CVS NASAL ALLERGY 24HR SPRAY

ADVOCATE INS SYR 1 ML 29GX1/2'' PREVACID 15 MG SOLUTAB CVS OMEPRAZOLE DR 20 MG TABLET

ADVOCATE INS SYR 1 ML 30GX5/16 PREVACID 30 MG SOLUTAB CVS OMEPRAZOLE MAG DR 20.6 MG

ADVOCATE LANCING DEVICE PREZCOBIX 800 MG-150 MG TABLET CVS OMEPRAZOLE-BICARB 20-1;100

ADVOCATE RAPID-SAFE LANCING PREZISTA 100 MG/ML SUSPENSION DESONIDE 0.05% CREAM

AEROCHAMBER MINI PREZISTA 150 MG TABLET DESONIDE 0.05% LOTION

AEROCHAMBER MV HOLD CHAMBER PREZISTA 600 MG TABLET DESONIDE 0.05% OINTMENT

AEROCHAMBER PLUS FLOW-VU PREZISTA 75 MG TABLET DESOXIMETASONE 0.05% CREAM

AEROCHAMBER PLUS FLOW-VU LARGE PREZISTA 800 MG TABLET DESOXIMETASONE 0.05% GEL

AEROCHAMBER PLUS FLOW-VU MED PYRIMETHAMINE 25 MG TABLET DESOXIMETASONE 0.05% OINTMENT

AEROCHAMBER PLUS FLOW-VU SMALL RECTIV 0.4% OINTMENT DESOXIMETASONE 0.25% CREAM

AEROCHAMBER PLUS W-FLOWSIGNAL RIVASTIGMINE 13.3 MG/24HR PTCH DESOXIMETASONE 0.25% OINTMENT

AEROCHAMBER Z-STAT PLUS LARGE RIVASTIGMINE 4.6 MG/24HR PATCH DEXAMETHASONE 0.5 MG TABLET

AEROCHAMBER Z-STAT PLUS W-FLOW RIVASTIGMINE 9.5 MG/24HR PATCH DEXAMETHASONE 0.5 MG/5 ML ELX

AEROCHAMBER Z-STAT PLUS-MED SAVELLA 100 MG TABLET DEXAMETHASONE 0.5 MG/5 ML LIQ

AEROCHAMBER Z-STAT PLUS-SMALL SAVELLA 12.5 MG TABLET DEXAMETHASONE 0.75 MG TABLET

AEROVENT PLUS HOLDING CHAMBER SAVELLA 25 MG TABLET DEXAMETHASONE 1 MG TABLET

AFLURIA QUAD 2019-20 (3YR UP) SAVELLA 50 MG TABLET DEXAMETHASONE 1.5 MG TABLET

AFLURIA QUAD 2019-20 (6-35MO) SAVELLA TITRATION PACK DEXAMETHASONE 2 MG TABLET

AFLURIA QUAD 2019-2020 VIAL SELZENTRY 150 MG TABLET DEXAMETHASONE 4 MG TABLET

AIMSCO LATEX CONDOM SELZENTRY 20 MG/ML ORAL SOLN DEXAMETHASONE 6 MG TABLET

AIRZONE PEAK FLOW METER SELZENTRY 25 MG TABLET DICLOFENAC POT 50 MG TABLET

Page 5: Appendix F5. Maryland Physicians Care (MPC)

Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System

Appendix F5 5

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

AK-POLY-BAC EYE OINTMENT SELZENTRY 300 MG TABLET DICLOFENAC SOD DR 25 MG TAB

ALA-CORT 1% CREAM SELZENTRY 75 MG TABLET DICLOFENAC SOD DR 50 MG TAB

ALAVERT 10 MG ODT SILDENAFIL 20 MG TABLET DICLOFENAC SOD DR 75 MG TAB

ALAVERT D-12 ALLERGY-SINUS TAB SPORANOX 10 MG/ML SOLUTION DICLOFENAC SOD EC 25 MG TAB

ALAWAY 0.025% EYE DROPS STAVUDINE 15 MG CAPSULE DICLOFENAC SOD EC 50 MG TAB

ALBUSTIX REAGENT STRIPS STAVUDINE 20 MG CAPSULE DICLOFENAC SOD EC 75 MG TAB

ALBUTEROL 2.5 MG/0.5 ML SOL STAVUDINE 30 MG CAPSULE DICLOFENAC SOD ER 100 MG TAB

ALBUTEROL HFA 90 MCG INHALER STAVUDINE 40 MG CAPSULE DIFLORASONE 0.05% CREAM

ALBUTEROL SUL 0.63 MG/3 ML SOL STRIBILD TABLET DIFLORASONE 0.05% OINTMENT

ALBUTEROL SUL 1.25 MG/3 ML SOL SUSTIVA 200 MG CAPSULE DORZOLAMIDE HCL 2% EYE DROPS

ALBUTEROL SUL 2.5 MG/3 ML SOLN SUSTIVA 50 MG CAPSULE DORZOLAMIDE-TIMOLOL EYE DROPS

ALCLOMETASONE DIPR 0.05% OINT SUSTIVA 600 MG TABLET DOXYCYCLINE HYC DR 100 MG TAB

ALCLOMETASONE DIPRO 0.05% CRM SYMTUZA 800-150-200-10 MG TAB DOXYCYCLINE HYC DR 150 MG TAB

ALCOH-GLOVE CONTOURED WIPE TECFIDERA DR 120 MG CAPSULE DOXYCYCLINE HYC DR 75 MG TAB

ALCOHOL 70% PADS TECFIDERA DR 240 MG CAPSULE DOXYCYCLINE HYCLATE 20 MG TAB

ALCOHOL 70% PREP PADS TECFIDERA STARTER PACK DOXYCYCLINE MONO 100 MG CAP

ALCOHOL 70% SWABS TEMIXYS 300-300 MG TABLET DOXYCYCLINE MONO 100 MG TABLET

ALCOHOL PREP PADS TESTOSTERON ENAN 1;000 MG/5 ML DOXYCYCLINE MONO 150 MG TABLET

ALCOHOL SWAB TESTOSTERONE 12.5 MG/1.25 GRAM DOXYCYCLINE MONO 50 MG CAP

ALCOHOL SWABS TESTOSTERONE 25 MG/2.5 GM PKT DOXYCYCLINE MONO 50 MG TABLET

ALCOH-WIPE 12''X12'' FLAT WIPE TESTOSTERONE 50 MG/5 GRAM PKT DOXYCYCLINE MONO 75 MG CAPSULE

ALENDRONATE SODIUM 10 MG TAB TESTOSTERONE ENAN 200 MG/ML DOXYCYCLINE MONO 75 MG TABLET

ALENDRONATE SODIUM 35 MG TAB TIBSOVO 250 MG TABLET EC-NAPROXEN DR 375 MG TABLET

ALENDRONATE SODIUM 5 MG TABLET TIVICAY 10 MG TABLET EC-NAPROXEN DR 500 MG TABLET

ALENDRONATE SODIUM 70 MG TAB TIVICAY 25 MG TABLET ELIDEL 1% CREAM

ALER-CAPS 25 MG CAPSULE TIVICAY 50 MG TABLET ELIGARD 22.5 MG SYRINGE KIT

ALFALFA FLAVOR POWDER TRACLEER 125 MG TABLET ELIGARD 30 MG SYRINGE KIT

ALFUZOSIN HCL ER 10 MG TABLET TRACLEER 62.5 MG TABLET ELIGARD 45 MG SYRINGE KIT

ALIVE WOMEN'S ENERGY MV TABLET TRAMADOL HCL 50 MG TABLET ELIGARD 7.5 MG SYRINGE KIT

ALKA-SELTZER PLUS ALLERGY TAB TRAMADOL-ACETAMINOPHN 37.5-325 ENDOCET 10-325 MG TABLET

ALL DAY ALLERGY 10 MG TABLET TRIUMEQ 600-50-300 MG TABLET ENDOCET 2.5-325 MG TABLET

ALL DAY ALLERGY-D TABLET TRIZIVIR TABLET ENDOCET 5-325 TABLET

ALLER-CHLOR 4 MG TABLET TYMLOS 80 MCG DOSE PEN INJECTR ENDOCET 7.5-325 MG TABLET

Page 6: Appendix F5. Maryland Physicians Care (MPC)

Appendix F5. Maryland Physicians Care (MPC) Prescription Drugs Subject to NQTLs, by Delivery System

Appendix F5 6

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ALLERCLEAR 10 MG TABLET VALGANCICLOVIR HCL 50 MG/ML EPINASTINE HCL 0.05% EYE DROPS

ALLERCLEAR D-12HR TABLET VANCOCIN HCL 125 MG CAPSULE EQ ACID REDUCER 20 MG TABLET

ALLERCLEAR D-24HR ER TABLET VANCOMYCIN HCL 125 MG CAPSULE EQ ACID REDUCER 200 MG TABLET

ALLER-EASE 60 MG TABLET VANCOMYCIN HCL 250 MG CAPSULE EQ ALLERGY RELIEF 50 MCG SPRAY

ALLER-FEX 180 MG TABLET VIRACEPT 250 MG TABLET EQ CHILD IBUPROFEN 100 MG/5 ML

ALLER-G-TIME 25 MG CAPLET VIRACEPT 625 MG TABLET EQ IBUPROFEN 200 MG CAPLET

ALLERGY (LORATADINE) 10 MG TAB WIXELA 100-50 INHUB EQ IBUPROFEN 200 MG TABLET

ALLERGY 25 MG CAPSULE WIXELA 250-50 INHUB EQ LANSOPRAZOLE DR 15 MG CAP

ALLERGY 25 MG SOFTGEL WIXELA 500-50 INHUB EQ NASAL ALLERGY 24HR SPRAY

ALLERGY 25 MG TABLET N/A EQ OMEPRAZOLE DR 20 MG TABLET

ALLERGY 4 MG TABLET N/A EQ OMEPRAZOLE MAG DR 20.6 MG

ALLERGY RELIEF 10 MG ODT N/A EQL CHLD IBUPROFEN 100 MG/5 ML

ALLERGY RELIEF 10 MG TABLET N/A EQL FLUTICASONE PROP 50 MCG

ALLERGY RELIEF 180 MG TABLET N/A EQL HEARTBURN PREVEN 20 MG TAB

ALLERGY RELIEF 25 MG CAPSULE N/A EQL IBUPROFEN 200 MG CAPLET

ALLERGY RELIEF 25 MG SOFTGEL N/A EQL IBUPROFEN 200 MG TABLET

ALLERGY RELIEF 25 MG TABLET N/A EQL LANSOPRAZOLE DR 15 MG CAP

ALLERGY RELIEF 4 MG TABLET N/A EQL OMEPRAZOLE DR 20 MG TABLET

ALLERGY RELIEF 5 MG/5 ML SOLN N/A ETODOLAC 200 MG CAPSULE

ALLERGY RELIEF 50 MCG SPRAY N/A ETODOLAC 300 MG CAPSULE

ALLERGY RELIEF D 12-HOUR TAB N/A ETODOLAC 400 MG TABLET

ALLERGY RELIEF D-12 TABLET N/A ETODOLAC 500 MG TABLET

ALLERGY RELIEF D-24HR TABLET N/A ETODOLAC ER 400 MG TABLET

ALLERGY RELIEF-D 12 HOUR TAB N/A ETODOLAC ER 500 MG TABLET

ALLERGY RELIEF-D TABLET N/A ETODOLAC ER 600 MG TABLET

ALLERGY RELIEF-NASAL DECONG TB N/A EXEMESTANE 25 MG TABLET

ALLERGY RLF (CETRZN) 10 MG TAB N/A EYE ITCH RELIEF 0.025% DROPS

ALLERGY-CONGES RELF ER TABLET N/A EZETIMIBE 10 MG TABLET

ALLERGY-CONGEST RLF-D 24HR TAB N/A EZETIMIBE-SIMVASTATIN 10-10 MG

ALLERGY-CONGESTION RLF 12H TAB N/A EZETIMIBE-SIMVASTATIN 10-20 MG

ALLERGY-TIME 4 MG TABLET N/A EZETIMIBE-SIMVASTATIN 10-40 MG

ALLER-TEC 10 MG TABLET N/A EZETIMIBE-SIMVASTATIN 10-80 MG

ALLER-TEC D 5-120 MG TABLET N/A FAMOTIDINE 20 MG TABLET

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Appendix F5 7

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ALLOPURINOL 100 MG TABLET N/A FAMOTIDINE 40 MG TABLET

ALLOPURINOL 300 MG TABLET N/A FEBUXOSTAT 40 MG TABLET

ALOCRIL 2% EYE DROPS N/A FEBUXOSTAT 80 MG TABLET

ALOGLIPTIN 12.5 MG TABLET N/A FENOPROFEN 600 MG TABLET

ALOGLIPTIN 25 MG TABLET N/A FENTANYL 100 MCG/HR PATCH

ALOGLIPTIN 6.25 MG TABLET N/A FENTANYL 12 MCG/HR PATCH

ALOGLIPTIN-METFORMIN 12.5-1000 N/A FENTANYL 25 MCG/HR PATCH

ALOGLIPTIN-METFORMIN 12.5-500 N/A FENTANYL 37.5 MCG/HR PATCH

ALOGLIPTIN-PIOGLIT 12.5-15 MG N/A FENTANYL 50 MCG/HR PATCH

ALOGLIPTIN-PIOGLIT 12.5-30 MG N/A FENTANYL 62.5 MCG/HR PATCH

ALOGLIPTIN-PIOGLIT 12.5-45 MG N/A FENTANYL 75 MCG/HR PATCH

ALOGLIPTIN-PIOGLIT 25-15 MG TB N/A FENTANYL 87.5 MCG/HR PATCH

ALOGLIPTIN-PIOGLIT 25-30 MG TB N/A FIRMAGON 2 X 120 MG KIT

ALOGLIPTIN-PIOGLIT 25-45 MG TB N/A FIRMAGON 80 MG KIT

ALTAVERA-28 TABLET N/A FIRST-LANSOPRAZOLE 3 MG/ML

ALTERNATE SITE 26G LANCETS N/A FIRST-OMEPRAZOLE 2 MG/ML SUSP

ALTERNATE SITE LANCING DEVICE N/A FLONASE ALLERGY RLF 50 MCG SPR

ALUMINUM CHLORIDE CRYSTALS N/A FLUNISOLIDE 0.025% SPRAY

ALUMINUM CHLORIDE POWDER N/A FLUOCINOLONE 0.01% BODY OIL

ALUMINUM HYDROXIDE GEL N/A FLUOCINOLONE 0.01% CREAM

ALYACEN 1-35 28 TABLET N/A FLUOCINOLONE 0.01% SCALP OIL

ALYACEN 7-7-7-28 TABLET N/A FLUOCINOLONE 0.01% SOLUTION

AMANTADINE 100 MG CAPSULE N/A FLUOCINOLONE 0.025% CREAM

AMANTADINE 100 MG TABLET N/A FLUOCINOLONE 0.025% OINTMENT

AMANTADINE 100 MG/10 ML SOLN N/A FLUOCINONIDE 0.05% CREAM

AMANTADINE 50 MG/5 ML SOLUTION N/A FLUOCINONIDE 0.05% GEL

AMBRISENTAN 10 MG TABLET N/A FLUOCINONIDE 0.05% OINTMENT

AMBRISENTAN 5 MG TABLET N/A FLUOCINONIDE 0.05% SOLUTION

AMCINONIDE 0.1% CREAM N/A FLUOCINONIDE 0.1% CREAM

AMCINONIDE 0.1% LOTION N/A FLUOCINONIDE-E 0.05% CREAM

AMERIPHOR MOIST OINTMENT N/A FLURBIPROFEN 100 MG TABLET

AMETHIA 0.15-0.03-0.01 MG TAB N/A FLUTAMIDE 125 MG CAPSULE

AMETHIA LO TABLET N/A FLUTICASONE PROP 0.005% OINT

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Appendix F5 8

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

AMETHYST 90-20 MCG TABLET N/A FLUTICASONE PROP 0.05% CREAM

AMILORIDE HCL 5 MG TABLET N/A FLUTICASONE PROP 0.05% LOTION

AMILORIDE HCL-HCTZ 5-50 MG TAB N/A FLUTICASONE PROP 50 MCG SPRAY

AMIODARONE HCL 100 MG TABLET N/A GARDASIL 9 SYRINGE

AMIODARONE HCL 200 MG TABLET N/A GARDASIL 9 VIAL

AMIODARONE HCL 400 MG TABLET N/A GLIPIZIDE-METFORMIN 2.5-250 MG

AMLODIPINE BESYLATE 10 MG TAB N/A GLIPIZIDE-METFORMIN 2.5-500 MG

AMLODIPINE BESYLATE 2.5 MG TAB N/A GLIPIZIDE-METFORMIN 5-500 MG

AMLODIPINE BESYLATE 5 MG TAB N/A GLYBURIDE-METFORMIN 2.5-500 MG

AMLODIPINE-BENAZEPRIL 10-20 MG N/A GLYBURIDE-METFORMIN 5-500 MG

AMLODIPINE-BENAZEPRIL 10-40 MG N/A GLYBURID-METFORMIN 1.25-250 MG

AMLODIPINE-BENAZEPRIL 2.5-10 N/A GNP ACID REDUCER 20 MG TABLET

AMLODIPINE-BENAZEPRIL 5-10 MG N/A GNP CHLD IBUPROFEN 100 MG/5 ML

AMLODIPINE-BENAZEPRIL 5-20 MG N/A GNP CIMETIDINE 200 MG TABLET

AMLODIPINE-BENAZEPRIL 5-40 MG N/A GNP IBUPROFEN 200 MG CAPLET

AMLODIPINE-VALSARTAN 10-160 MG N/A GNP IBUPROFEN 200 MG TABLET

AMLODIPINE-VALSARTAN 10-320 MG N/A GNP OMEPRAZOLE DR 20 MG TABLET

AMLODIPINE-VALSARTAN 5-160 MG N/A GS CHILD IBUPROFEN 100 MG/5 ML

AMLODIPINE-VALSARTAN 5-320 MG N/A GS IBUPROFEN 200 MG CAPLET

AMLOD-VALSA-HCTZ 10-160-12.5MG N/A GS IBUPROFEN 200 MG TABLET

AMLOD-VALSA-HCTZ 10-160-25 MG N/A GS ITCHY EYE 0.025% DROPS

AMLOD-VALSA-HCTZ 10-320-25 MG N/A GS LANSOPRAZOLE DR 15 MG CAP

AMLOD-VALSA-HCTZ 5-160-12.5 MG N/A GS NASAL ALLERGY 24HR SPRAY

AMLOD-VALSA-HCTZ 5-160-25 MG N/A GS OMEPRAZOLE DR 20 MG TABLET

AMMONIUM LACTATE 12% CREAM N/A GUANFACINE HCL ER 1 MG TABLET

AMMONIUM LACTATE 12% LOTION N/A GUANFACINE HCL ER 2 MG TABLET

AMOX-CLAV 200-28.5 MG TAB CHEW N/A GUANFACINE HCL ER 3 MG TABLET

AMOX-CLAV 200-28.5 MG/5 ML SUS N/A GUANFACINE HCL ER 4 MG TABLET

AMOX-CLAV 250-125 MG TABLET N/A HALOBETASOL PROP 0.05% CREAM

AMOX-CLAV 250-62.5 MG/5 ML SUS N/A HALOBETASOL PROP 0.05% OINTMNT

AMOX-CLAV 400-57 MG TAB CHEW N/A HEARTBURN RELIEF 20 MG TABLET

AMOX-CLAV 400-57 MG/5 ML SUSP N/A HEARTBURN RELIEF 200 MG TABLET

AMOX-CLAV 500-125 MG TABLET N/A HEARTBURN TREATMNT 24 HR 15 MG

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Appendix F5 9

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

AMOX-CLAV 600-42.9 MG/5 ML SUS N/A HM ALLERGY RELIEF 50 MCG SPRAY

AMOX-CLAV 875-125 MG TABLET N/A HM CHILD IBUPROFEN 100 MG/5 ML

AMOXICILLIN 125 MG TAB CHEW N/A HM EYE ITCH RELIEF 0.025% DROP

AMOXICILLIN 200 MG/5 ML SUSP N/A HM FAMOTIDINE 20 MG TABLET

AMOXICILLIN 250 MG TAB CHEW N/A HM IBUPROFEN 200 MG CAPLET

AMOXICILLIN 250 MG/5 ML SUSP N/A HM IBUPROFEN 200 MG TABLET

AMOXICILLIN 400 MG/5 ML SUSP N/A HM IBUPROFEN IB 200 MG CAPLET

AMOXICILLIN 500 MG CAPSULE N/A HM IBUPROFEN IB 200 MG TABLET

AMOXICILLIN 500 MG TABLET N/A HM LANSOPRAZOLE DR 15 MG CAP

AMOXICILLIN 875 MG TABLET N/A HM OMEPRAZOLE DR 20 MG TABLET

AMOXICILLIN TRIHYDRATE POWDER N/A HYDROCODONE-ACETAMIN 10-300 MG

AMPHOTERICIN B POWDER N/A HYDROCODONE-ACETAMIN 10-325 MG

AMPICILLIN 250 MG CAPSULE N/A HYDROCODONE-ACETAMIN 2.5-325

AMPICILLIN 500 MG CAPSULE N/A HYDROCODONE-ACETAMIN 5-300 MG

ANAGRELIDE HCL 0.5 MG CAPSULE N/A HYDROCODONE-ACETAMIN 5-325 MG

ANAGRELIDE HCL 1 MG CAPSULE N/A HYDROCODONE-ACETAMIN 7.5-300

ANASTROZOLE 1 MG TABLET N/A HYDROCODONE-ACETAMIN 7.5-325

ANEFRIN 0.05% NASAL SPRAY N/A HYDROCODONE-ACETAMN 7.5-325/15

ANISE EXTRACT FLAVOR N/A HYDROCODONE-IBUPROFEN 10-200

ANISE OIL N/A HYDROCODONE-IBUPROFEN 5-200 MG

ANORO ELLIPTA 62.5-25 MCG INH N/A HYDROCODONE-IBUPROFEN 7.5-200

ANTACID 500 MG CHEW TABLET N/A HYDROCORTISONE 10 MG TABLET

ANTACID 500 MG CHEWABLE TABLET N/A HYDROCORTISONE 2.5% CREAM

ANTACID 750 MG CHEW TABLET N/A HYDROCORTISONE 2.5% LOTION

ANTACID 750 MG CHEWABLE TABLET N/A HYDROCORTISONE 2.5% OINTMENT

ANTACID CALCIUM 500 MG CHW TAB N/A HYDROCORTISONE 20 MG TABLET

ANTACID EX-STR 750 MG TAB CHEW N/A HYDROCORTISONE 5 MG TABLET

ANTACID EX-STR TABLET CHEW N/A HYDROCORTISONE BUTY 0.1% CREAM

ANTACID ULTRA STR 1;000 MG CHW N/A HYDROCORTISONE BUTYR 0.1% OINT

ANTACID ULTRA STR TAB CHEWABLE N/A HYDROCORTISONE BUTYR 0.1% SOLN

ANTACID ULTRA TABLET CHEW N/A HYDROCORTISONE VAL 0.2% CREAM

ANTACID XTRA STRENGTH CHEW TAB N/A HYDROCORTISONE VAL 0.2% OINTMT

ANTHRALIN POWDER N/A HYDROMORPHONE 2 MG TABLET

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Appendix F5 10

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ANTI-DIARRHEAL 2 MG CAPLET N/A HYDROMORPHONE 4 MG TABLET

ANTI-DIARRHEAL 2 MG SOFTGEL N/A HYDROMORPHONE 8 MG TABLET

ANTI-DIARRHEAL 2 MG TABLET N/A HYDROXYUREA 500 MG CAPSULE

ANTIFUNGAL 1% TOPICAL CREAM N/A IBU 400 MG TABLET

ANTIFUNGAL 2% TOPICAL CREAM N/A IBU 600 MG TABLET

ANTI-ITCH 1% CREAM N/A IBU 800 MG TABLET

ANTI-ITCH 1% LOTION N/A IBU-200 200 MG TABLET

ANTIOXIDANT FORMULA TABLET N/A IBUDONE 10-200 MG TABLET

APPLE FLAVOR N/A IBUPROFEN 100 MG/5 ML SUSP

APPLE FLAVOR LIQUID N/A IBUPROFEN 200 MG CAPLET

APPLE FLAVOR POWDER N/A IBUPROFEN 200 MG TABLET

APPLE-ADE FLAVOR LIQUID N/A IBUPROFEN 400 MG TABLET

APRI 28 DAY TABLET N/A IBUPROFEN 600 MG TABLET

APRICOT FLAVOR LIQUID N/A IBUPROFEN 800 MG TABLET

APRICOT FLAVOR POWDER N/A ICLUSIG 15 MG TABLET

APRISO ER 0.375 GRAM CAPSULE N/A INCRUSE ELLIPTA 62.5 MCG INH

APTIVUS 100 MG/ML SOLUTION N/A INDOMETHACIN 25 MG CAPSULE

APTIVUS 250 MG CAPSULE N/A INDOMETHACIN 50 MG CAPSULE

AQUA CARE STERILE WATER IRRIG N/A INDOMETHACIN ER 75 MG CAPSULE

AQUA LANCE LANCING DEVICE N/A I-PRIN 200 MG TABLET

AQUANIL HC 1% LOTION N/A JANTOVEN 1 MG TABLET

ARANELLE 28 TABLET N/A JANTOVEN 10 MG TABLET

ARCAPTA NEOHALER 75 MCG CAP N/A JANTOVEN 2 MG TABLET

ARIXTRA 2.5 MG/0.5 ML SYRINGE N/A JANTOVEN 2.5 MG TABLET

ARIXTRA 5 MG/0.4 ML SYRINGE N/A JANTOVEN 3 MG TABLET

ARIXTRA 7.5 MG/0.6 ML SYRINGE N/A JANTOVEN 4 MG TABLET

ARMOUR THYROID 120 MG TABLET N/A JANTOVEN 5 MG TABLET

ARMOUR THYROID 15 MG TABLET N/A JANTOVEN 6 MG TABLET

ARMOUR THYROID 180 MG TABLET N/A JANTOVEN 7.5 MG TABLET

ARMOUR THYROID 240 MG TABLET N/A KETOPROFEN 50 MG CAPSULE

ARMOUR THYROID 300 MG TABLET N/A KETOPROFEN 75 MG CAPSULE

ARNUITY ELLIPTA 100 MCG INH N/A KETOPROFEN ER 200 MG CAPSULE

ARNUITY ELLIPTA 200 MCG INH N/A KETOROLAC 10 MG TABLET

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Appendix F5 11

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ARNUITY ELLIPTA 50 MCG INH N/A KETOTIFEN FUM 0.025% EYE DROPS

ARTHRITIS PAIN ER 650 MG CAPLT N/A KRO CHLD IBUPROFEN 100 MG/5 ML

ARTHRITIS PAIN ER 650 MG GELTB N/A KRO IBUPROFEN 200 MG CAPLET

ARTHRITIS PAIN RELF ER 650 MG N/A KRO IBUPROFEN 200 MG TABLET

ARTHRITIS PAIN RELIEF 0.1% CRM N/A LANSOPRAZOLE DR 15 MG CAPSULE

ARTHRITIS PAIN RLF ER 650 MG N/A LANSOPRAZOLE DR 30 MG CAPSULE

ASA-BUTALB-CAFF-COD #3 CAPSULE N/A LANSOPRAZOLE ODT 15 MG TABLET

ASACOL HD DR 800 MG TABLET N/A LANSOPRAZOLE ODT 30 MG TABLET

ASCOMP WITH CODEINE CAPSULE N/A LETROZOLE 2.5 MG TABLET

ASHLYNA 0.15-0.03-0.01 MG TAB N/A LEUPROLIDE 2WK 1 MG/0.2 ML KIT

ASPIR EC 81 MG TABLET N/A LEUPROLIDE 2WK 14 MG/2.8 ML KT

ASPIRIN 325 MG TABLET N/A LEVALBUTEROL TAR HFA 45MCG INH

ASPIRIN EC 325 MG TABLET N/A LORCET 5-325 MG TABLET

ASPIRIN EC 81 MG TABLET N/A LORCET HD 10-325 MG TABLET

ASPIRIN POWDER N/A LORCET PLUS 7.5-325 MG TABLET

ASSURE COMFORT 28G LANCETS N/A LUPRON DEPOT 22.5 MG 3MO KIT

ASSURE COMFORT 30G LANCETS N/A LUPRON DEPOT 45 MG 6MO KIT

ASSURE HAEMOLANCE PLUS 18G N/A LUPRON DEPOT 7.5 MG KIT

ASSURE HAEMOLANCE PLUS 21G N/A LUPRON DEPOT-4 MONTH KIT

ASSURE HAEMOLANCE PLUS 25G N/A MECLOFENAMATE 100 MG CAPSULE

ASSURE HAEMOLANCE PLUS 28G N/A MECLOFENAMATE 50 MG CAPSULE

ASSURE HAEMOLANCE PLUS BLADE N/A MELOXICAM 15 MG TABLET

ASSURE ID SYR 0.5 ML 29GX1/2'' N/A MELOXICAM 7.5 MG TABLET

ASSURE ID SYR 1 ML 29GX1/2'' N/A MEPERIDINE 100 MG TABLET

ASSURE LANCE 25G LANCETS N/A MEPERIDINE 50 MG TABLET

ASSURE LANCE 28G LANCETS N/A MERCAPTOPURINE 50 MG TABLET

ASSURE LANCE 28G SAFETY LANCET N/A METFORMIN ER 500 MG GASTRC-TB

ASSURE LANCE PLUS 21G LANCETS N/A METFORMIN ER 500 MG OSMOTIC TB

ASSURE LANCE PLUS 25G LANCETS N/A METFORMIN HCL 1;000 MG TABLET

ASSURE LANCE PLUS 30G LANCETS N/A METFORMIN HCL 500 MG TABLET

ASTHMA CHECK PEAK FLOW MTR N/A METFORMIN HCL 850 MG TABLET

ATAZANAVIR SULFATE 150 MG CAP N/A METFORMIN HCL ER 500 MG TABLET

ATAZANAVIR SULFATE 200 MG CAP N/A METFORMIN HCL ER 750 MG TABLET

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Appendix F5 12

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ATAZANAVIR SULFATE 300 MG CAP N/A METHADONE 10 MG/5 ML SOLUTION

ATENOLOL 100 MG TABLET N/A METHADONE 10 MG/ML ORAL CONC

ATENOLOL 25 MG TABLET N/A METHADONE 5 MG/5 ML SOLUTION

ATENOLOL 50 MG TABLET N/A METHADONE HCL 10 MG TABLET

ATENOLOL POWDER N/A METHADONE HCL 5 MG TABLET

ATENOLOL-CHLORTHALIDONE 100-25 N/A METHADONE INTENSOL 10 MG/ML

ATENOLOL-CHLORTHALIDONE 50-25 N/A METHOTREXATE 1 GRAM/40 ML VIAL

ATHLETES FOOT 1% CREAM N/A METHOTREXATE 25 MG/ML VIAL

ATHLETE'S FOOT 1% CREAM N/A METHOTREXATE 250 MG/10 ML VIAL

ATORVASTATIN 10 MG TABLET N/A METHOTREXATE 50 MG/2 ML VIAL

ATORVASTATIN 20 MG TABLET N/A METHYLPREDNISOLONE 16 MG TAB

ATORVASTATIN 40 MG TABLET N/A METHYLPREDNISOLONE 32 MG TAB

ATORVASTATIN 80 MG TABLET N/A METHYLPREDNISOLONE 4 MG DOSEPK

ATRIPLA TABLET N/A METHYLPREDNISOLONE 4 MG TABLET

ATROPINE 1% EYE DROPS N/A METHYLPREDNISOLONE 8 MG TAB

ATROPINE 1% EYE OINTMENT N/A MINOCYCLINE 100 MG CAPSULE

ATROVENT 17 MCG HFA INHALER N/A MINOCYCLINE 50 MG CAPSULE

AUBAGIO 14 MG TABLET N/A MINOCYCLINE 75 MG CAPSULE

AUBAGIO 7 MG TABLET N/A MINOCYCLINE ER 105 MG TABLET

AUBRA-28 TABLET N/A MINOCYCLINE ER 80 MG TABLET

AUTOJECT 2 INJECTION DEVICE N/A MOMETASONE FUROATE 0.1% CREAM

AUTO-LANCET MINI LANCING DEV N/A MOMETASONE FUROATE 0.1% OINT

AUTOLET IMPRESS LANCING DEVICE N/A MOMETASONE FUROATE 0.1% SOLN

AUTOLET LANCING DEVICE N/A MONTELUKAST SOD 10 MG TABLET

AUTOLET PLUS LANCING DEVICE N/A MONTELUKAST SOD 4 MG GRANULES

AVEENO 1% CREAM N/A MONTELUKAST SOD 4 MG TAB CHEW

AVIANE-28 TABLET N/A MONTELUKAST SOD 5 MG TAB CHEW

AVITA 0.025% GEL N/A MORPHINE SULF 10 MG SUPPOS

AZATHIOPRINE 50 MG TABLET N/A MORPHINE SULF 10 MG/5 ML SOLN

AZATHIOPRINE POWDER N/A MORPHINE SULF 100 MG/5 ML CONC

AZEDRA DOSIMETRIC VIAL N/A MORPHINE SULF 20 MG SUPPOS

AZEDRA THERAPEUTIC VIAL N/A MORPHINE SULF 20 MG/5 ML SOLN

AZELASTINE 0.1% (137 MCG) SPRY N/A MORPHINE SULF 30 MG SUPPOS

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Appendix F5 13

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

AZELASTINE HCL 0.05% DROPS N/A MORPHINE SULF 5 MG SUPPOS

AZITHROMYCIN 1 GM PWD PACKET N/A MORPHINE SULF ER 100 MG TABLET

AZITHROMYCIN 100 MG/5 ML SUSP N/A MORPHINE SULF ER 15 MG TABLET

AZITHROMYCIN 200 MG/5 ML SUSP N/A MORPHINE SULF ER 200 MG TABLET

AZITHROMYCIN 250 MG TABLET N/A MORPHINE SULF ER 30 MG TABLET

AZITHROMYCIN 500 MG TABLET N/A MORPHINE SULF ER 60 MG TABLET

AZITHROMYCIN 600 MG TABLET N/A MORPHINE SULFATE IR 15 MG TAB

AZOPT 1% EYE DROPS N/A MORPHINE SULFATE IR 30 MG TAB

AZURETTE 28 DAY TABLET N/A MOTRIN IB 200 MG CAPLET

B COMPLEX WITH VITAMIN C TAB N/A MYORISAN 10 MG CAPSULE

B-6 TR 200 MG TABLET N/A MYORISAN 20 MG CAPSULE

BACITRACIN 500 UNIT/GM OPHTH N/A MYORISAN 30 MG CAPSULE

BACITRACIN POWDER N/A MYORISAN 40 MG CAPSULE

BACITRACIN-POLYMYXIN EYE OINT N/A NABUMETONE 500 MG TABLET

BACLOFEN 10 MG TABLET N/A NABUMETONE 750 MG TABLET

BACLOFEN 20 MG TABLET N/A NAPROXEN 125 MG/5 ML SUSPEN

BACLOFEN POWDER N/A NAPROXEN 250 MG TABLET

BALZIVA 28 TABLET N/A NAPROXEN 375 MG TABLET

BANANA CREAM FLAVOR LIQUID N/A NAPROXEN 500 MG KIT

BANANA CREME FLAVOR LIQUID N/A NAPROXEN 500 MG TABLET

BANANA FLAVOR ARTIFICIAL LIQ N/A NAPROXEN DR 375 MG TABLET

BANANA FLAVOR CONCENTRATE LIQ N/A NAPROXEN DR 500 MG TABLET

BANANA FLAVOR LIQUID N/A NAPROXEN SODIUM 275 MG TAB

BANOPHEN 25 MG CAPSULE N/A NASACORT ALLERGY 24HR SPRAY

BANOPHEN 25 MG TABLET N/A NASAL ALLERGY 24HR SPRAY

BANOPHEN 50 MG CAPSULE N/A NEXIUM 24HR 20 MG CAPSULE

BARACLUDE 0.05 MG/ML SOLUTION N/A NEXIUM DR 10 MG PACKET

BARACLUDE 0.5 MG TABLET N/A NEXIUM DR 2.5 MG PACKET

BARACLUDE 1 MG TABLET N/A NEXIUM DR 20 MG CAPSULE

BASAGLAR 100 UNIT/ML KWIKPEN N/A NEXIUM DR 20 MG PACKET

BASE GELATIN GUMMY TROCHE N/A NEXIUM DR 40 MG CAPSULE

BASE; CUSTOM POLYGLYCOL TROCHE N/A NEXIUM DR 40 MG PACKET

BASE; PCCA ACACIA SYRUP N/A NEXIUM DR 5 MG PACKET

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Appendix F5 14

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

BASE; PCCA BITTER DRUG POWD N/A NIZATIDINE 15 MG/ML SOLUTION

BASE; PCCA SYRUP VEHICLE N/A NIZATIDINE 150 MG CAPSULE

BAYER ASPIRIN 325 MG CAPLET N/A NIZATIDINE 300 MG CAPSULE

BAYER ASPIRIN 325 MG TABLET N/A OMEPRAZOLE DR 20 MG TABLET

BAZA ANTIFUNGAL 2% CREAM N/A OMEPRAZOLE MAG DR 20 MG CAP

B-COMPLEX PLUS VITAMIN C CPLT N/A OMEPRAZOLE MAG DR 20.6 MG CAP

B-COMPLEX WITH C TABLET N/A OMEPRAZOLE-BICARB 20-1;100 CAP

B-COMPLEX WITH VIT C CAPLET N/A OMEPRAZOLE-BICARB 40-1;100 CAP

B-COMPLEX WITH VIT C TABLET N/A OXAPROZIN 600 MG CAPLET

B-COMPLEX W-VITAMIN C CAPLET N/A OXAPROZIN 600 MG TABLET

BD 3 ML SYRINGE WITH NEEDLE N/A OXYBUTYNIN 5 MG TABLET

BD ECLIPSE SYRINGE 3 ML 22GX1'' N/A OXYBUTYNIN 5 MG/5 ML SYRUP

BD INS SYR 0.3 ML 8MMX31G(1/2) N/A OXYBUTYNIN CL ER 10 MG TABLET

BD INS SYR U-500 1/2ML 6MMX31G N/A OXYBUTYNIN CL ER 15 MG TABLET

BD INS SYR UF 0.3ML 12.7MMX30G N/A OXYBUTYNIN CL ER 5 MG TABLET

BD INS SYR UF 0.5ML 12.7MMX30G N/A OXYCODON-ACETAMINOPHEN 2.5-325

BD INS SYRN UF 1 ML 12.7MMX30G N/A OXYCODON-ACETAMINOPHEN 7.5-325

BD INS SYRNG 0.3 ML 29GX12.7MM N/A OXYCODONE HCL 10 MG TABLET

BD INS SYRNG 0.5 ML 29GX12.7MM N/A OXYCODONE HCL 100 MG/5 ML CONC

BD INS SYRNG UF 0.3 ML 8MMX31G N/A OXYCODONE HCL 15 MG TABLET

BD INS SYRNG UF 0.5 ML 8MMX31G N/A OXYCODONE HCL 20 MG TABLET

BD INSULIN SYR 0.5 ML 28GX1/2'' N/A OXYCODONE HCL 30 MG TABLET

BD INSULIN SYR 0.5 ML 29GX1/2'' N/A OXYCODONE HCL 5 MG CAPSULE

BD INSULIN SYR 1 ML 25GX5/8'' N/A OXYCODONE HCL 5 MG TABLET

BD INSULIN SYR 1 ML 27GX5/8'' N/A OXYCODONE HCL 5 MG/5 ML SOLN

BD INSULIN SYR 1 ML 28GX1/2'' N/A OXYCODONE-ACETAMINOPHEN 10-325

BD INSULIN SYR 1 ML 29GX1/2'' N/A OXYCODONE-ACETAMINOPHEN 5-325

BD INSULIN SYR 1 ML 29GX12.7MM N/A OXYMORPHONE HCL ER 10 MG TAB

BD INSULIN SYR UF 1 ML 8MMX31G N/A OXYMORPHONE HCL ER 15 MG TAB

BD INSULIN SYRINGE 1 ML N/A OXYMORPHONE HCL ER 20 MG TAB

BD LANCETS 33G N/A OXYMORPHONE HCL ER 30 MG TAB

BD LUER-LOK SYRINGE 1 ML N/A OXYMORPHONE HCL ER 40 MG TAB

BD MICROTAINER 21G LANCETS N/A OXYMORPHONE HCL ER 5 MG TABLET

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Appendix F5 15

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

BD MICROTAINER 30G LANCETS N/A OXYMORPHONE HCL ER 7.5 MG TAB

BD MICROTAINER LANCETS N/A PANTOPRAZOLE SOD DR 20 MG TAB

BD SAFETGLD INS 0.3 ML 8MMX31G N/A PANTOPRAZOLE SOD DR 40 MG TAB

BD SAFETGLD INS 0.3ML 13MMX29G N/A PARICALCITOL 1 MCG CAPSULE

BD SAFETGLD INS 0.5 ML 8MMX30G N/A PARICALCITOL 2 MCG CAPSULE

BD SAFETGLD INS 0.5ML 13MMX29G N/A PARICALCITOL 4 MCG CAPSULE

BD SAFETYGLD INS 1 ML 13MMX29G N/A PEGASYS 180 MCG/0.5 ML SYRINGE

BD SINGLE USE SWAB N/A PEGASYS 180 MCG/ML VIAL

BD UF INS SYR 1 ML 30GX1/2'' N/A PEGINTRON 50 MCG KIT

BD ULTRA-FINE 33G LANCETS N/A PIMECROLIMUS 1% CREAM

BD ULTRA-FINE II 30G LANCETS N/A PIOGLITAZONE-METFORMIN 15-500

BD VEO INS SYRN 0.3 ML 6MMX31G N/A PIOGLITAZONE-METFORMIN 15-850

BD VEO INS SYRN 0.5 ML 6MMX31G N/A PIROXICAM 10 MG CAPSULE

BENAZEPRIL HCL 10 MG TABLET N/A PIROXICAM 20 MG CAPSULE

BENAZEPRIL HCL 20 MG TABLET N/A POTELIGEO 20 MG/5 ML VIAL

BENAZEPRIL HCL 40 MG TABLET N/A PREDNICARBATE 0.1% CREAM

BENAZEPRIL HCL 5 MG TABLET N/A PREDNICARBATE 0.1% OINTMENT

BENAZEPRIL-HCTZ 10-12.5 MG TAB N/A PREDNISOLONE 15 MG/5 ML SOLN

BENAZEPRIL-HCTZ 20-12.5 MG TAB N/A PREDNISOLONE 5 MG/5 ML SOLN

BENAZEPRIL-HCTZ 20-25 MG TAB N/A PREDNISOLONE SOD PH 25 MG/5 ML

BENAZEPRIL-HCTZ 5-6.25 MG TAB N/A PREDNISONE 1 MG TABLET

BENZNIDAZOLE 100 MG TABLET N/A PREDNISONE 10 MG TABLET

BENZONATATE 100 MG CAPSULE N/A PREDNISONE 2.5 MG TABLET

BENZONATATE 200 MG CAPSULE N/A PREDNISONE 20 MG TABLET

BENZONATATE PERLE 100 MG CAP N/A PREDNISONE 5 MG TABLET

BENZOYL PEROXIDE 2.5% GEL N/A PREDNISONE 5 MG/5 ML SOLUTION

BENZOYL PEROXIDE 5% GEL N/A PREDNISONE 50 MG TABLET

BENZOYL PEROXIDE 5% WASH N/A PREDNISONE INTENSOL 5 MG/ML

BENZYL ALCOHOL LIQUID N/A PREVACID 15 MG SOLUTAB

BENZYL BENZOATE LIQUID N/A PREVACID 30 MG SOLUTAB

BETA HC 1% LOTION N/A PROCTO-MED HC 2.5% CREAM

BETAMETHASONE DP 0.05% CRM N/A PROCTO-PAK 1% CREAM

BETAMETHASONE DP 0.05% LOT N/A PROCTOSOL-HC 2.5% CREAM

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Appendix F5 16

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

BETAMETHASONE DP 0.05% OINT N/A PROCTOZONE-HC 2.5% CREAM

BETAMETHASONE DP AUG 0.05% CRM N/A PROVIL 200 MG TABLET

BETAMETHASONE DP AUG 0.05% GEL N/A PUB CHILDREN'S PROFEN IB SUSP

BETAMETHASONE DP AUG 0.05% LOT N/A PUB CHILDREN'S PROFENIB SUSP

BETAMETHASONE DP AUG 0.05% OIN N/A PUB FAMOTIDINE 20 MG TABLET

BETAMETHASONE DP POWDER N/A PUB IBUPROFEN 200 MG TABLET

BETAMETHASONE VA 0.1% CREAM N/A PUB OMEPRAZOLE DR 20 MG TABLET

BETAMETHASONE VA 0.1% LOTION N/A QC ALLERGY RELIEF 50 MCG SPRAY

BETAMETHASONE VALER 0.1% OINTM N/A QC CHILD IBUPROFEN 100 MG/5 ML

BETAMETHASONE VALERATE POWDER N/A QC FLUTICASONE PROP 50 MCG

BETATAR GEL SHAMPOO N/A QC IBUPROFEN 200 MG CAPLET

BETAXOLOL 10 MG TABLET N/A QC IBUPROFEN IB 200 MG CAPLET

BETAXOLOL 20 MG TABLET N/A QC IBUPROFEN IB 200 MG TABLET

BETAXOLOL HCL 0.5% EYE DROP N/A QC OMEPRAZOLE MAG DR 20.6 MG

BETHANECHOL 10 MG TABLET N/A RA ACID REDUCER 20 MG TABLET

BETHANECHOL 25 MG TABLET N/A RA BUDESONIDE 32 MCG SPRAY

BETHANECHOL 5 MG TABLET N/A RA CHILD IBUPROFEN 100 MG/5 ML

BETHANECHOL 50 MG TABLET N/A RA EYE ITCH RELIEF 0.025% DROP

BETHANECHOL CHLORIDE POWDER N/A RA IBUPROFEN 100 MG/5 ML SUSP

BEVESPI AEROSPHERE INHALER N/A RA IBUPROFEN 200 MG CAPLET

BEXSERO PREFILLED SYRINGE N/A RA IBUPROFEN 200 MG TABLET

BEYAZ 28 TABLET N/A RA LANSOPRAZOLE DR 15 MG CAP

BICALUTAMIDE 50 MG TABLET N/A RA NASAL ALLERGY 24HR SPRAY

BIKTARVY 50-200-25 MG TABLET N/A RA OMEPRAZOLE DR 20 MG TABLET

BIOCOTRON LIQUID N/A RABEPRAZOLE SOD DR 20 MG TAB

BIODESP DM LIQUID N/A REPAGLINIDE-METFORMIN 1-500 MG

BIOGIL LIQUID N/A REPAGLINIDE-METFORMIN 2-500 MG

BIOTIN PLUS-CALCIUM & VIT D3 N/A REVLIMID 10 MG CAPSULE

BISACODYL POWDER N/A REVLIMID 15 MG CAPSULE

BISMATROL 525 MG/15 ML SUSP N/A REVLIMID 2.5 MG CAPSULE

BISMATROL 525 MG/30 ML SUSP N/A REVLIMID 25 MG CAPSULE

BISOPROLOL FUMARATE 10 MG TAB N/A REVLIMID 5 MG CAPSULE

BISOPROLOL FUMARATE 5 MG TAB N/A RHINOCORT ALLERGY 32 MCG SPRAY

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Appendix F5 17

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

BISOPROLOL-HCTZ 10-6.25 MG TAB N/A RIBAVIRIN 200 MG CAPSULE

BISOPROLOL-HCTZ 2.5-6.25 MG TB N/A RIBAVIRIN 200 MG TABLET

BISOPROLOL-HCTZ 5-6.25 MG TAB N/A SIMVASTATIN 10 MG TABLET

BITTER STOP FLAVOR LIQUID N/A SIMVASTATIN 20 MG TABLET

BITTERNESS MASK FLAVOR LIQUID N/A SIMVASTATIN 40 MG TABLET

BITTERNESS REDUCING AGENT PWD N/A SIMVASTATIN 5 MG TABLET

BITTERNESS SUPPRESSOR LIQUID N/A SIMVASTATIN 80 MG TABLET

BLACKBERRY FLAVOR LIQUID N/A SM ACID REDUCER 20 MG TABLET

BLEPHAMIDE EYE DROPS N/A SM ACID REDUCER 200 MG TABLET

BLEPHAMIDE EYE OINTMENT N/A SM ALLERGY RELIEF 50 MCG SPRAY

BLISOVI 24 FE TABLET N/A SM EYE ITCH RELIEF 0.025% DROP

BLISOVI FE 1-20 TABLET N/A SM IBUPROFEN 100 MG/5 ML SUSP

BLOOD LANCETS 30G N/A SM IBUPROFEN 200 MG CAPLET

BLUEBERRY FLAVOR LIQUID N/A SM IBUPROFEN 200 MG TABLET

BOSULIF 100 MG TABLET N/A SM IBUPROFEN IB 200 MG CAPLET

BOSULIF 500 MG TABLET N/A SM IBUPROFEN IB 200 MG TABLET

BP 5% GEL N/A SM LANSOPRAZOLE DR 15 MG CAP

BP WASH 2.5% LIQUID N/A SM OMEPRAZOLE DR 20 MG TABLET

BP WASH 5% LIQUID N/A SOVALDI 400 MG TABLET

BREATHERITE MDI SPACER N/A STIOLTO RESPIMAT INHAL SPRAY

BREATHERITE SPACER-ADULT MASK N/A STIVARGA 40 MG TABLET

BREATHERITE SPACER-INFANT MASK N/A SULINDAC 150 MG TABLET

BREATHERITE SPACER-LG CHLD MSK N/A SULINDAC 200 MG TABLET

BREATHERITE SPACER-NEONATE MSK N/A SW OMEPRAZOLE DR 20 MG TABLET

BREATHERITE SPACER-SM CHLD MSK N/A TABLOID 40 MG TABLET

BREATHRITE VALVED MDI CHAMBER N/A TACROLIMUS 0.03% OINTMENT

BREATHRITE VALVED MDI SPACER N/A TACROLIMUS 0.1% OINTMENT

BRIELLYN TABLET N/A TETRACYCLINE 250 MG CAPSULE

BRIMONIDINE 0.2% EYE DROP N/A TETRACYCLINE 500 MG CAPSULE

BRIMONIDINE TARTRATE 0.15% DRP N/A TIBSOVO 250 MG TABLET

BROMOCRIPTINE 2.5 MG TABLET N/A TOLMETIN SODIUM 200 MG TAB

BROMOCRIPTINE 5 MG CAPSULE N/A TOLMETIN SODIUM 400 MG CAP

BROMOCRIPTINE MESYLATE POWDER N/A TOLMETIN SODIUM 600 MG TAB

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Appendix F5 18

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

BROMPHENIRAMINE MALEATE POWDER N/A TOLTERODINE TARTRATE 1 MG TAB

BRONCOTRON PED DROPS N/A TOLTERODINE TARTRATE 2 MG TAB

BRONCOTRON PED LIQUID N/A TRAMADOL HCL 50 MG TABLET

BROOKS INSULIN 0.3ML SYRN N/A TRAMADOL-ACETAMINOPHN 37.5-325

BUBBLE GUM FLAVOR CONC LIQUID N/A TRETINOIN 0.01% GEL

BUBBLE GUM FLAVOR LIQUID N/A TRETINOIN 0.025% CREAM

BUDESONIDE 0.25 MG/2 ML SUSP N/A TRETINOIN 0.025% GEL

BUDESONIDE 0.5 MG/2 ML SUSP N/A TRETINOIN 0.05% CREAM

BUDESONIDE 1 MG/2 ML INH SUSP N/A TRETINOIN 0.1% CREAM

BUDESONIDE 32 MCG NASAL SPRAY N/A TRETINOIN 10 MG CAPSULE

BUDESONIDE ER 9 MG TABLET N/A TRIAMCINOLONE 0.025% CREAM

BULLSEYE MINI SAFETY 21G N/A TRIAMCINOLONE 0.025% LOTION

BULLSEYE MINI SAFETY 25G LANCT N/A TRIAMCINOLONE 0.025% OINT

BULLSEYE MINI SAFETY 28G LANCT N/A TRIAMCINOLONE 0.1% CREAM

BUMETANIDE 0.5 MG TABLET N/A TRIAMCINOLONE 0.1% LOTION

BUMETANIDE 1 MG TABLET N/A TRIAMCINOLONE 0.1% OINTMENT

BUMETANIDE 2 MG TABLET N/A TRIAMCINOLONE 0.5% CREAM

BUTALB-ACETAMIN-CAFF 50-325-40 N/A TRIAMCINOLONE 0.5% OINTMENT

BUTALB-CAFF-ACETAMINOPH-CODEIN N/A TRIAMCINOLONE 55 MCG NASAL SPR

BUTALBITAL COMP-CODEINE #3 CAP N/A TRIANEX 0.05% OINTMENT

BUTALBITAL-ACETAMINOPHN 50-325 N/A TROSPIUM CHLORIDE 20 MG TABLET

BUTALBITAL-ASA-CAFFEINE CAP N/A TROSPIUM CHLORIDE ER 60 MG CAP

BUTORPHANOL 10 MG/ML SPRAY N/A TRULICITY 0.75 MG/0.5 ML PEN

BUTTER FLAVOR LIQUID N/A TRULICITY 1.5 MG/0.5 ML PEN

BUTTER RUM FLAVOR N/A TYKERB 250 MG TABLET

BUTTER RUM FLAVOR LIQUID N/A ULORIC 40 MG TABLET

BUTTERSCOTCH FLAVOR LIQUID N/A ULORIC 80 MG TABLET

BYSTOLIC 10 MG TABLET N/A VOTRIENT 200 MG TABLET

BYSTOLIC 2.5 MG TABLET N/A VYTORIN 10-10 MG TABLET

BYSTOLIC 20 MG TABLET N/A VYTORIN 10-20 MG TABLET

BYSTOLIC 5 MG TABLET N/A VYTORIN 10-40 MG TABLET

CA INS SYR 0.3 ML 30GX5/16'' N/A VYTORIN 10-80 MG TABLET

CA INS SYR 0.3 ML 31GX5/16'' N/A WAL-PROFEN 200 MG CAPLET

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Appendix F5 19

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CA INS SYR 0.5 ML 30GX5/16'' N/A WAL-PROFEN 200 MG TABLET

CA INS SYR 0.5 ML 31GX5/16'' N/A WAL-ZYR 0.025% EYE DROPS

CA INSULIN SYR 0.3 ML 29GX1/2'' N/A WARFARIN SODIUM 1 MG TABLET

CA INSULIN SYR 0.5 ML 29GX1/2'' N/A WARFARIN SODIUM 10 MG TABLET

CA INSULIN SYR 1 ML 29GX1/2'' N/A WARFARIN SODIUM 2 MG TABLET

CA INSULIN SYR 1 ML 30GX5/16'' N/A WARFARIN SODIUM 2.5 MG TABLET

CA INSULIN SYR 1 ML 31GX5/16'' N/A WARFARIN SODIUM 3 MG TABLET

CABERGOLINE 0.5 MG TABLET N/A WARFARIN SODIUM 4 MG TABLET

CAFFEINE POWDER N/A WARFARIN SODIUM 5 MG TABLET

CAL MAG ZINC-D TABLET N/A WARFARIN SODIUM 6 MG TABLET

CAL MAG ZINC-D3 TABLET N/A WARFARIN SODIUM 7.5 MG TABLET

CALCIDOL DROPS N/ACALCIPOTRIENE 0.005% CREAM N/ACALCIPOTRIENE 0.005% OINTMENT N/ACALCIPOTRIENE 0.005% SOLUTION N/ACALCITONIN-SALMON 200 UNITS SP N/ACALCITRIOL 0.25 MCG CAPSULE N/ACALCITRIOL 0.5 MCG CAPSULE N/ACALCITRIOL 1 MCG/ML SOLUTION N/ACALCITRIOL 3 MCG/G OINTMENT N/ACALCIUM + D3 ER TABLET N/ACALCIUM 500 MG CHEWABLE TABLET N/ACALCIUM 600 + VIT D 400 SOFTGL N/ACALCIUM 600 MG PLUS VIT D TAB N/ACALCIUM 600 MG TABLET N/ACALCIUM 600 MG-VIT D3 10MCG TB N/ACALCIUM 600+D PLUS MINERALS TB N/ACALCIUM 600+D SOFTGEL N/ACALCIUM 600-VIT D3 200 TABLET N/ACALCIUM 600-VIT D3 400 CAPLET N/ACALCIUM 600-VIT D3 400 TABLET N/ACALCIUM 600-VIT D3 800 CAPLET N/ACALCIUM 600-VIT D3 800 TABLET N/A

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Appendix F5 20

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CALCIUM 600-VIT D3-MIN CHEW TB N/ACALCIUM ANTACID 1;000 MG TAB N/ACALCIUM ANTACID 500 MG CHW TAB N/ACALCIUM ANTACID 750 MG TB CHEW N/ACALCIUM ANTACID EX-STR CHEW N/ACALCIUM ANTACID EX-STR TABLET N/ACALCIUM ANTACID ULTRA-STR CHEW N/ACALCIUM CARB 500 MG TAB CHEW N/ACALCIUM CARBONATE 750 MG CHEW N/ACALCIUM CARBONATE POWDER N/ACALCIUM CIT 200-VIT D3 250 TAB N/ACALCIUM CIT 250 MG-D3 200 UNIT N/ACALCIUM CIT 315 MG-D3 250 UNIT N/ACALCIUM CIT 315-VIT D3 250 CPT N/ACALCIUM CITRATE - VIT D3 TAB N/ACALCIUM CITRATE 250 MG CAPLET N/ACALCIUM CITRATE 250 MG TABLET N/ACALCIUM CITRATE PLUS TABLET N/ACALCIUM CITRATE-VIT D CAPLET N/ACALCIUM CITRATE-VIT D3 CAPLET N/ACALCIUM CITRATE-VIT D3 TABLET N/ACALCIUM FOLINATE POWDER N/ACAL-GEST 500 MG TABLET CHEW N/ACAMILA 0.35 MG TABLET N/ACAMRESE 0.15-0.03-0.01 MG TAB N/ACAMRESE LO TABLET N/ACANASA 1;000 MG SUPPOSITORY N/ACANDESARTAN CILEXETIL 16 MG TB N/ACANDESARTAN CILEXETIL 32 MG TB N/ACANDESARTAN CILEXETIL 4 MG TAB N/ACANDESARTAN CILEXETIL 8 MG TAB N/ACANDESARTAN-HCTZ 16-12.5 MG TB N/ACANDESARTAN-HCTZ 32-12.5 MG TB N/A

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Appendix F5 21

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CANDESARTAN-HCTZ 32-25 MG TAB N/ACAPECITABINE 150 MG TABLET N/ACAPECITABINE 500 MG TABLET N/ACAPSAICIN 0.025% CREAM N/ACAPSAICIN POWDER N/ACAPSULE #0 N/ACAPSULE #00 N/ACAPSULE #000 N/ACAPSULE #1 N/ACAPSULE #1 BLUE-PWD BLUE N/ACAPSULE #1 RED-WHITE N/ACAPSULE #10 N/ACAPSULE #11 N/ACAPSULE #13 N/ACAPSULE #2 N/ACAPSULE #3 N/ACAPSULE #4 N/ACAPSULE #5 N/ACAPSULE #7 N/ACAPSULE CONI-SNAP #0 N/ACAPSULE CONI-SNAP #00 N/ACAPSULE CONI-SNAP #000 N/ACAPSULE CONI-SNAP #1 N/ACAPSULE CONI-SNAP #2 N/ACAPSULE CONI-SNAP #3 N/ACAPSULE CONI-SNAP #4 N/ACAPTOPRIL 100 MG TABLET N/ACAPTOPRIL 12.5 MG TABLET N/ACAPTOPRIL 25 MG TABLET N/ACAPTOPRIL 50 MG TABLET N/ACAPTOPRIL-HCTZ 25-15 MG TABLET N/ACAPTOPRIL-HCTZ 25-25 MG TABLET N/ACAPTOPRIL-HCTZ 50-15 MG TABLET N/A

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Appendix F5 22

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CAPTOPRIL-HCTZ 50-25 MG TABLET N/ACARAFATE 1 GM/10 ML SUSP N/ACARAMEL FLAVOR LIQUID N/ACARBIDOPA-LEVO ER 25-100 TAB N/ACARBIDOPA-LEVO ER 50-200 TAB N/ACARBIDOPA-LEVODOPA 10-100 TAB N/ACARBIDOPA-LEVODOPA 25-100 TAB N/ACARBIDOPA-LEVODOPA 25-250 TAB N/ACAREONE LANCING DEVICE N/ACAREONE SYR 0.3 ML 30GX1/2'' N/ACAREONE SYR 0.5 ML 30GX1/2'' N/ACAREONE SYR 1 ML 30GX1/2'' N/ACAREONE ULTRA THIN LANCET N/ACAREONE UNIFINE PENTIP 4MM 32G N/ACAREONE UNIFINE PENTIP 5MM 31G N/ACAREONE UNIFINE PENTIP 6MM 31G N/ACAREONE UNIFINE PENTIP 8MM 31G N/ACAREONE UNIFINE PENTP 29GX1/2'' N/ACAREONE UNIFINE PENTP 31GX1/4'' N/ACAREONE UNIFINE PNTP 12MM 29G N/ACAREONE UNIFINE PNTP 31GX3/16'' N/ACAREONE UNIFINE PNTP 31GX5/16'' N/ACAREONE UNIFINE PNTP 32GX5/32'' N/ACARETOUCH ALCOHOL 70% PREP PAD N/ACARETOUCH LANCING DEVICE N/ACARETOUCH PEN NEEDLE 31GX1/4'' N/ACARETOUCH PEN NEEDLE 31GX3/16'' N/ACARETOUCH PEN NEEDLE 31GX5/16'' N/ACARETOUCH PEN NEEDLE 32GX3/16'' N/ACARETOUCH PEN NEEDLE 32GX5/32'' N/ACARETOUCH TWIST 30G LANCET N/ACARISOPRODOL 350 MG TABLET N/ACARISOPRODOL POWDER N/A

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Appendix F5 23

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CARRINGTON ANTIFUNGAL 2% CREAM N/ACARTEOLOL HCL 1% EYE DROPS N/ACARTIA XT 120 MG CAPSULE N/ACARTIA XT 180 MG CAPSULE N/ACARTIA XT 240 MG CAPSULE N/ACARTIA XT 300 MG CAPSULE N/ACARVEDILOL 12.5 MG TABLET N/ACARVEDILOL 25 MG TABLET N/ACARVEDILOL 3.125 MG TABLET N/ACARVEDILOL 6.25 MG TABLET N/ACASTOR OIL N/ACAZIANT 28 DAY TABLET N/ACEFACLOR 125 MG/5 ML SUSP N/ACEFACLOR 250 MG CAPSULE N/ACEFACLOR 250 MG/5 ML SUSP N/ACEFACLOR 375 MG/5 ML SUSPEN N/ACEFACLOR 500 MG CAPSULE N/ACEFACLOR ER 500 MG TABLET N/ACEFADROXIL 1 GM TABLET N/ACEFADROXIL 250 MG/5 ML SUSP N/ACEFADROXIL 500 MG CAPSULE N/ACEFADROXIL 500 MG/5 ML SUSP N/ACEFDINIR 125 MG/5 ML SUSP N/ACEFDINIR 250 MG/5 ML SUSP N/ACEFDINIR 300 MG CAPSULE N/ACEFIXIME 100 MG/5 ML SUSP N/ACEFIXIME 200 MG/5 ML SUSP N/ACEFIXIME 400 MG CAPSULE N/ACEFPODOXIME 100 MG TABLET N/ACEFPODOXIME 100 MG/5 ML SUSP N/ACEFPODOXIME 200 MG TABLET N/ACEFPODOXIME 50 MG/5 ML SUSP N/ACEFPROZIL 125 MG/5 ML SUSP N/A

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Appendix F5 24

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CEFPROZIL 250 MG TABLET N/ACEFPROZIL 250 MG/5 ML SUSP N/ACEFPROZIL 500 MG TABLET N/ACEFTRIAXONE 1 GM VIAL N/ACEFTRIAXONE 2 GM VIAL N/ACEFTRIAXONE 250 MG VIAL N/ACEFTRIAXONE 500 MG VIAL N/ACEFUROXIME AXETIL 250 MG TAB N/ACEFUROXIME AXETIL 500 MG TAB N/ACEFUROXIME SOD 1.5 GM VIAL N/ACEFUROXIME SOD 750 MG VIAL N/ACELECOXIB 100 MG CAPSULE N/ACELECOXIB 200 MG CAPSULE N/ACELECOXIB 400 MG CAPSULE N/ACELECOXIB 50 MG CAPSULE N/ACELLCEPT 200 MG/ML ORAL SUSP N/ACELLCEPT 250 MG CAPSULE N/ACELLCEPT 500 MG TABLET N/ACELLCEPT 500 MG VIAL N/ACENTRAVITES 50 PLUS TABLET N/ACENTRAVITES ADULTS TABLET N/ACENTRAVITES TABLET N/ACENTRUM MEN'S TABLET N/ACENTRUM SILVER MEN TABLET N/ACENTRUM SILVER ULTRA MEN'S TAB N/ACENTRUM SILVER WOMEN TABLET N/ACENTRUM SPECIALIST HEART TAB N/ACENTRUM ULTRA MEN'S TABLET N/ACENTRUM WOMEN TABLET N/ACENTURY ADULTS 50 PLUS TABLET N/ACENTURY CARDIO TABLET N/ACENTURY TABLET N/ACENTURY ULTIMATE MEN'S TABLET N/A

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Appendix F5 25

Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CENTURY ULTIMATE WOMEN'S TAB N/ACEPHALEXIN 125 MG/5 ML SUSP N/ACEPHALEXIN 250 MG CAPSULE N/ACEPHALEXIN 250 MG TABLET N/ACEPHALEXIN 250 MG/5 ML SUSP N/ACEPHALEXIN 500 MG CAPSULE N/ACEPHALEXIN 500 MG TABLET N/ACEQUA 0.09% SOLUTION N/ACEROVITE ADVANCED FORM TAB N/ACEROVITE SENIOR TABLET N/ACERTA PLUS TABLET N/ACERTAVITE SR-ANTIOXIDANT TAB N/ACERTAVITE-ANTIOXIDANT TABLET N/ACETIRIZINE HCL 1 MG/ML SOLN N/ACETIRIZINE HCL 1 MG/ML SYRUP N/ACETIRIZINE HCL 10 MG CHEW TAB N/ACETIRIZINE HCL 10 MG TABLET N/ACETIRIZINE HCL 5 MG CHEW TAB N/ACETIRIZINE HCL 5 MG TABLET N/ACETIRIZINE HCL 5 MG/5 ML SOLN N/ACETIRIZINE-PSE ER 5-120 MG TAB N/ACHATEAL-28 TABLET N/ACHEESECAKE FLAVOR LIQUID N/ACHEK-STIX STRIPS N/ACHEMSTRIP 10 MD N/ACHEMSTRIP 10 WITH SG N/ACHEMSTRIP 2 GP N/ACHEMSTRIP 2 LN N/ACHEMSTRIP 50B N/ACHEMSTRIP 7 N/ACHEMSTRIP BG DIARY N/ACHEMSTRIP MICRAL TEST STRIP N/ACHEMSTRIP-9 N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CHERRY ARTIFICIAL FLAVOR LIQ N/ACHERRY CONCENTRATE FLAVOR LIQ N/ACHERRY FLAVOR CONC LIQUID N/ACHERRY FLAVOR LIQUID N/ACHERRY SYRUP N/ACHERRY-ADE FLAVOR POWDER N/ACHILD ACETAMINOPHEN 80 MG CHEW N/ACHILD ALL DAY ALLERGY 1 MG/ML N/ACHILD ALLERGY 5 MG/5 ML SOLN N/ACHILD ALLERGY RELIEF 1 MG/ML N/ACHILD ALLERGY RLF 12.5 MG/5 ML N/ACHILD CETIRIZINE 10 MG CHEW TB N/ACHILD CETIRIZINE 5 MG CHEW TAB N/ACHILD CETIRIZINE HCL 1 MG/ML N/ACHILD CHEW + IRON TAB CHEW N/ACHILD FERROUS SULFATE 15 MG/ML N/ACHILD LORATADINE 5 MG/5 ML SOL N/ACHILD LORATADINE 5 MG/5 ML SYR N/ACHILD MUCUS RELIEF COUGH LIQ N/ACHILD MUCUS RELIEF M-S COLD LQ N/ACHILD MUCUS-COUGH RELIEF LIQ N/ACHILD MULTI-SYMPTOM COLD LIQ N/ACHILD SOOTHE 400 MG TAB CHEW N/ACHILD TACTINAL 80 MG TAB CHW N/ACHILD VITAMIN-IRON TAB CHEW N/ACHILD WAL-ITIN 5 MG/5 ML SOLN N/ACHILD WAL-ITIN 5 MG/5 ML SYRUP N/ACHILD WAL-ZYR 1 MG/ML SOLUTION N/ACHILDREN IBUPROFEN 100 MG/5 ML N/ACHILDREN PEPTO 400 MG TAB CHEW N/ACHILDREN'S CHEST CONGEST LIQ N/ACHILDREN'S COUGH LIQUID N/ACHILDREN'S IRON 15 MG/ML DROPS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CHILDREN'S MAPAP 80 MG TAB CHW N/ACHILDREN'S MUCINEX COUGH LIQ N/ACHILDREN'S MUCUS RELIEF LIQ N/ACHILDREN'S SILAPAP ELIXIR N/ACHILD'S ALAWAY 0.025% EYE DROP N/ACHILD'S ALLERGY 12.5 MG/5 ML N/ACHILD'S CHEW VITAMIN-IRON TAB N/ACHILD'S EASY-MELTS 80 MG TAB N/ACHILD'S MULTI-SYMPTOM COLD LIQ N/ACHILD'S WAL-DRYL 12.5 MG/5 ML N/ACHILD'S WAL-ZYR 10 MG CHEW TAB N/ACHLORHEXIDINE 0.12% RINSE N/ACHLORHEXIDINE GLUC 20% SOLN N/ACHLORHIST 4 MG TABLET N/ACHLOROQUINE PH 250 MG TABLET N/ACHLOROQUINE PH 500 MG TABLET N/ACHLOROQUINE PHOSPHATE POWDER N/ACHLOROTHIAZIDE 500 MG TABLET N/ACHLORPHENIRAMINE 4 MG TABLET N/ACHLORPHENIRAMINE ER 12 MG TAB N/ACHLORPHENIRAMINE POWDER N/ACHLORTHALIDONE 25 MG TABLET N/ACHLORTHALIDONE 50 MG TABLET N/ACHLORZOXAZONE 500 MG TABLET N/ACHOCOLATE CONCENTRATE FLAVOR N/ACHOCOLATE FLAVOR LIQUID N/ACHOCOLATE FLAVOR POWDER N/ACHOCOLATE HAZELNUT FLAVOR LIQ N/ACHOLESTYRAMINE LIGHT PACKET N/ACHOLESTYRAMINE LIGHT POWDER N/ACHOLESTYRAMINE PACKET N/ACHOLESTYRAMINE POWDER N/ACHOLINE MAG TRISAL LIQUID N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CICLODAN 0.77% CREAM N/ACICLODAN 8% SOLUTION N/ACICLOPIROX 0.77% CREAM N/ACICLOPIROX 0.77% GEL N/ACICLOPIROX 0.77% TOPICAL SUSP N/ACICLOPIROX 1% SHAMPOO N/ACICLOPIROX 8% SOLUTION N/ACICLOPIROX OLAMINE POWDER N/ACILOSTAZOL 100 MG TABLET N/ACILOSTAZOL 50 MG TABLET N/ACILOXAN 0.3% OINTMENT N/ACIMDUO 300-300 MG TABLET N/ACIMETIDINE 200 MG TABLET N/ACIMETIDINE 300 MG TABLET N/ACIMETIDINE 300 MG/5 ML SOLN N/ACIMETIDINE 400 MG TABLET N/ACIMETIDINE 800 MG TABLET N/ACIMETIDINE POWDER N/ACINNAMON FLAVOR N/ACIPRODEX OTIC SUSPENSION N/ACIPROFLOXACIN 0.2% OTIC SOLN N/ACIPROFLOXACIN 0.3% EYE DROP N/ACIPROFLOXACIN HCL 250 MG TAB N/ACIPROFLOXACIN HCL 500 MG TAB N/ACIPROFLOXACIN HCL 750 MG TAB N/ACITRONELLA OIL N/ACITRUS CALCIUM 200-VIT D3 250 N/ACLARITHROMYCIN 125 MG/5 ML SUS N/ACLARITHROMYCIN 250 MG TABLET N/ACLARITHROMYCIN 250 MG/5 ML SUS N/ACLARITHROMYCIN 500 MG TABLET N/ACLARITHROMYCIN ER 500 MG TAB N/ACLARITIN 5 MG/5 ML SYRUP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CLEARLAX POWDER N/ACLEMASTINE FUM 2.68 MG TAB N/ACLEMASTINE FUMARATE POWDER N/ACLEOCIN 100 MG VAGINAL OVULE N/ACLEVER CHEK ULTRA THIN 30G N/ACLEVER CHOICE CHAMBER-LRG MASK N/ACLEVER CHOICE CHAMBER-MED MASK N/ACLEVER CHOICE CHAMBER-SM MASK N/ACLINDACIN ETZ 1% PLEDGET N/ACLINDACIN P 1% PLEDGETS N/ACLINDAMYCIN 2% VAGINAL CREAM N/ACLINDAMYCIN HCL 150 MG CAPSULE N/ACLINDAMYCIN HCL 300 MG CAPSULE N/ACLINDAMYCIN HCL 75 MG CAPSULE N/ACLINDAMYCIN PEDIATR 75 MG/5 ML N/ACLINDAMYCIN PH 1% GEL N/ACLINDAMYCIN PH 1% SOLUTION N/ACLINDAMYCIN PHOS 1% PLEDGET N/ACLINDAMYCIN PHOSP 1% LOTION N/ACLOBETASOL 0.05% CREAM N/ACLOBETASOL 0.05% GEL N/ACLOBETASOL 0.05% OINTMENT N/ACLOBETASOL 0.05% SHAMPOO N/ACLOBETASOL 0.05% SOLUTION N/ACLOBETASOL 0.05% TOPICAL LOTN N/ACLOBETASOL 17 PROP MICRO POWD N/ACLOBETASOL EMOLLIENT 0.05% CRM N/ACLOBETASOL PROP 0.05% FOAM N/ACLOBETASOL PROP MICRO POWDER N/ACLODAN 0.05% SHAMPOO N/ACLONIDINE 0.1 MG/DAY PATCH N/ACLONIDINE 0.2 MG/DAY PATCH N/ACLONIDINE 0.3 MG/DAY PATCH N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CLONIDINE HCL 0.1 MG TABLET N/ACLONIDINE HCL 0.2 MG TABLET N/ACLONIDINE HCL 0.3 MG TABLET N/ACLONIDINE HCL ER 0.1 MG TABLET N/ACLONIDINE HCL POWDER N/ACLOPIDOGREL 75 MG TABLET N/ACLOTRIMAZOLE 1% SOLUTION N/ACLOTRIMAZOLE 1% TOP CREAM GRX N/ACLOTRIMAZOLE 1% TOPICAL CREAM N/ACLOTRIMAZOLE 1% VAGINAL CREAM N/ACLOTRIMAZOLE 10 MG TROCHE N/ACLOTRIMAZOLE CRYSTALLINE N/ACLOTRIMAZOLE POWDER N/ACLOTRIMAZOLE-7 VAGINAL CREAM N/ACLOTRIMAZOLE-BETAMETHASONE CRM N/ACLOTRIMAZOLE-BETAMETHASONE LOT N/ACLOVE FLAVOR N/ACOAGUCHEK LANCETS N/ACOAL TAR N/ACOAL TAR SOLUTION N/ACOAL TAR TOPICAL SOLUTION N/ACOCONUT FLAVOR LIQUID N/ACODEINE SULFATE 15 MG TABLET N/ACODEINE SULFATE 30 MG TABLET N/ACODEINE SULFATE 60 MG TABLET N/ACODEINE-GUAIFEN 10-100 MG/5 ML N/ACOFFEE FLAVOR LIQUID N/ACOLA FLAVOR LIQUID N/ACOLA SYRUP N/ACOLCHICINE POWDER N/ACOLESTIPOL HCL 1 GM TABLET N/ACOLESTIPOL HCL GRANULES N/ACOLESTIPOL HCL GRANULES PACKET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

COLESTIPOL MICRONIZED 1 GM TAB N/ACOLOCORT 100 MG/60 ML ENEMA N/ACOMBIGAN 0.2%-0.5% EYE DROPS N/ACOMBIPATCH 0.05-0.14 MG PTCH N/ACOMBIPATCH 0.05-0.25 MG PTCH N/ACOMBISTIX REAGENT STRIPS N/ACOMBIVENT RESPIMAT 20-100 MCG N/ACOMBIVIR TABLET N/ACOMETRIQ 100 MG DAILY-DOSE PK N/ACOMETRIQ 140 MG DAILY-DOSE PK N/ACOMETRIQ 60 MG DAILY-DOSE PACK N/ACOMFORT EZ INS 0.3ML 30GX1/2'' N/ACOMFORT EZ INS 0.3ML 30GX5/16'' N/ACOMFORT EZ INS 0.5ML 31GX5/16'' N/ACOMFORT EZ INS 1 ML 31GX5/16'' N/ACOMFORT EZ INSULIN SYR 0.3 ML N/ACOMFORT EZ INSULIN SYR 0.5 ML N/ACOMFORT EZ SYR 0.3 ML 29GX1/2'' N/ACOMFORT EZ SYR 0.5 ML 28GX1/2'' N/ACOMFORT EZ SYR 0.5 ML 29GX1/2'' N/ACOMFORT EZ SYR 0.5 ML 30GX1/2'' N/ACOMFORT EZ SYR 1 ML 28GX1/2'' N/ACOMFORT EZ SYR 1 ML 29GX1/2'' N/ACOMFORT EZ SYR 1 ML 30GX1/2'' N/ACOMFORT EZ SYR 1 ML 30GX5/16'' N/ACOMFORT LANCETS N/ACOMFORT POINT PEN NDL 29GX1/2'' N/ACOMFORT POINT PEN NDL 31GX1/3'' N/ACOMFORT POINT PEN NDL 31GX1/4'' N/ACOMFORT POINT PEN NDL 31GX1/6'' N/ACOMPACT SPACE CHAMBER N/ACOMPACT SPACE CHAMBER-LRG MASK N/ACOMPACT SPACE CHAMBER-MED MASK N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

COMPACT SPACE CHAMBER-SM MASK N/ACOMPANION TABLET N/ACOMPLERA TABLET N/ACOMPLETE ALLERGY 25 MG CAPLET N/ACOMPLETE MULTI 50+ TABLET N/ACOMPLETE MULTI TABLET N/ACOMPLETE MULTIVITAMIN TAB N/ACOMPLETE NATAL DHA N/ACOMPLT ALLERGY MED 25 MG CP N/ACOMPRO 25 MG SUPPOSITORY N/ACONCEPT DHA CAPSULE N/ACONDOMS LUBRICATED N/ACONDYLOX 0.5% GEL N/ACONSTULOSE 10 GM/15 ML SOLN N/ACORAL CALCIUM POWDER N/ACORTIFOAM 10% AEROSOL N/ACORTISONE 25 MG TABLET N/ACORTISONE ACETATE POWDER N/ACORTIZONE-10 1% CREME N/ACORTIZONE-10 1% LOTION N/ACORTIZONE-10 1% OINTMENT N/ACORTIZONE-10 PLUS 1% CREME N/ACORTIZONE-10 PLUS CREME N/ACOTTON CANDY FLAVOR LIQUID N/ACOTTONSEED OIL N/ACOVARYX H.S. TABLET N/ACOVARYX TABLET N/ACRAN-RASPBERRY FLAVOR LIQUID N/ACREON DR 12;000 UNITS CAPSULE N/ACREON DR 24;000 UNITS CAPSULE N/ACREON DR 3;000 UNITS CAPSULE N/ACREON DR 36;000 UNITS CAPSULE N/ACREON DR 6;000 UNITS CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CRESTOR 10 MG TABLET N/ACRESTOR 20 MG TABLET N/ACRESTOR 40 MG TABLET N/ACRESTOR 5 MG TABLET N/ACRIXIVAN 200 MG CAPSULE N/ACRIXIVAN 400 MG CAPSULE N/ACROMOLYN 20 MG/2 ML NEB SOLN N/ACROMOLYN 4% EYE DROPS N/ACROMOLYN SODIUM POWDER N/ACRYSELLE-28 TABLET N/ACRYSVITA 10 MG/ML VIAL N/ACRYSVITA 20 MG/ML VIAL N/ACRYSVITA 30 MG/ML VIAL N/ACUPRIMINE 250 MG CAPSULE N/ACURITY ALCOHOL PREPS N/ACURITY STERILE WATER;IRRIGATIO N/ACVS ACETAMINOPHEN 500 MG CPLT N/ACVS ACETAMINOPHEN 500 MG GELCP N/ACVS ACETAMINOPHEN 500 MG TAB N/ACVS ACID CONTROLLER 20 MG TAB N/ACVS ACNE 10% CREAM N/ACVS ACNE SPOT TRTMENT 2.5% CRM N/ACVS ADULT DM MAXIMUM LIQUID N/ACVS ALCOHOL 70% PREP PADS N/ACVS ALLERGY (CETRZN) 10 MG TAB N/ACVS ALLERGY (LORAT) 10 MG TAB N/ACVS ALLERGY 0.025% EYE DROPS N/ACVS ALLERGY 25 MG CAPSULE N/ACVS ALLERGY 25 MG SOFTGEL N/ACVS ALLERGY 50 MG/20 ML LIQ N/ACVS ALLERGY RELIEF 180 MG TAB N/ACVS ALLERGY RELIEF 25 MG CAP N/ACVS ALLERGY RELIEF 25 MG TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CVS ALLERGY RELIEF 4 MG TABLET N/ACVS ALLERGY RELIEF 5 MG/5 ML N/ACVS ALLERGY RELIEF 60 MG TAB N/ACVS ALLERGY RELIEF D-24HR TAB N/ACVS ALLERGY RELIEF-D TABLET N/ACVS ALLERGY RELIEF-D12 TABLET N/ACVS ALLERGY RLF-D 60-120 MG TB N/ACVS ANTACID 750 MG CHEW TABLET N/ACVS ANTACID ULTRA TAB CHEW N/ACVS ANTACID XTRA STR CHEW TAB N/ACVS ANTIBIOTIC OINTMENT N/ACVS ANTI-DIARRHEAL 2 MG CAPLET N/ACVS ANTI-DIARRHEAL 2 MG SFTGEL N/ACVS ANTI-DIARRHEAL SUSPENSION N/ACVS ANTI-ITCH 1% CREAM N/ACVS ARTHRIT PAIN RLF ER 650 MG N/ACVS ASPIRIN 325 MG CAPLET N/ACVS ASPIRIN 325 MG TABLET N/ACVS ASPIRIN EC 325 MG TABLET N/ACVS ASPIRIN EC 81 MG TABLET N/ACVS ATHLETE'S FOOT 1% CREAM N/ACVS B-COMPLEX-VIT C CAPLET N/ACVS BUDESONIDE 32 MCG SPRAY N/ACVS CAL CIT 200 MG-D3 6.25 MCG N/ACVS CAL CIT 315 MG-D3 6.25 MCG N/ACVS CALCIUM 600 MG TABLET N/ACVS CALCIUM 600-VIT D3 800 TAB N/ACVS CALCIUM ANTACID 1;000 MG N/ACVS CAPSAICIN 0.1% CREAM N/ACVS CASTOR OIL N/ACVS CHILD ALLERGY 12.5 MG/5 ML N/ACVS CHILD ALLERGY RELF 1 MG/ML N/ACVS CHILD ALLERGY RLF 30 MG/5 N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CVS CHILD CHEST CONGEST-COUGH N/ACVS CHILD MULTI-SYMP COLD LIQ N/ACVS CHILD'S CHEST CONGEST LIQ N/ACVS CHLD IBUPROFEN 100 MG/5 ML N/ACVS CIMETIDINE 200 MG TABLET N/ACVS CLOTRIMAZOLE 1% SOLUTION N/ACVS CLOTRIMAZOLE 1% TOP CREAM N/ACVS CORTISONE 1% CREAM N/ACVS CORTISONE WITH ALOE 1% CRM N/ACVS DAILY MULTIPLE TABLET N/ACVS EYE ITCH RELIEF 0.025% DRP N/ACVS FIBER 0.52 G CAPSULE N/ACVS FIBER THERAPY CAPSULE N/ACVS FISH OIL 1;000 MG SOFTGEL N/ACVS FISH OIL 1;200 MG SOFTGEL N/ACVS FLUTICASONE PROP 50 MCG N/ACVS FOLIC ACID 800 MCG TABLET N/ACVS GAS RELIEF 80 MG TAB CHEW N/ACVS GAS RELIEF EX-STR DROPS N/ACVS GLUCOSE 4 GRAM TABLET CHEW N/ACVS HAIR; SKIN AND NAILS CPLT N/ACVS HYDROCORTISONE 1% CREAM N/ACVS IBUPROFEN 200 MG CAPLET N/ACVS IBUPROFEN 200 MG TABLET N/ACVS INFT GAS RLF 20 MG/0.3 ML N/ACVS IRON 65 MG TABLET N/ACVS ISOPROPYL ALCOHOL 70% WIPE N/ACVS ITCH RELIEF 1% TOP CREAM N/ACVS JOCK ITCH 1% CREAM N/ACVS KETONE CARE TEST STRIP N/ACVS KIDS ANTACID 750 MG CHEW N/ACVS LANCING DEVICE N/ACVS LANSOPRAZOLE DR 15 MG CAP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CVS LICE KILLING SHAMPOO N/ACVS LICE TREATMENT 1% CRM RINS N/ACVS LUBRICANT 0.5% EYE DROP N/ACVS LUBRICANT 0.5% EYE DROPS N/ACVS MICONAZOLE 3 COMBO PACK N/ACVS MICONAZOLE 7 CREAM N/ACVS MICRO THIN 33G LANCETS N/ACVS MOTION SICKNESS II TABLET N/ACVS MOTION SICKNESS RELIEF TAB N/ACVS NASAL ALLERGY 24HR SPRAY N/ACVS NASAL SPRAY 0.05% N/ACVS NATURAL DAILY FIBER POWDER N/ACVS NATURAL FIBER SUPP POWDER N/ACVS NIGHTTIME SLEEP 25 MG TAB N/ACVS NON-ASPIRIN 500 MG CAPLET N/ACVS NON-ASPIRIN 500 MG GELTAB N/ACVS OMEPRAZOLE DR 20 MG TABLET N/ACVS OMEPRAZOLE MAG DR 20.6 MG N/ACVS OMEPRAZOLE-BICARB 20-1;100 N/ACVS ONE DAILY WOMEN'S 50 PLUS N/ACVS PAIN RELIEF 325 MG TABLET N/ACVS PAIN RELIEF 500 MG CAPLET N/ACVS PAIN RELIEF 500 MG TABLET N/ACVS PAIN RELIEVER 500 MG CPLT N/ACVS PRENATAL VITAMINS TABLET N/ACVS PURELAX POWDER N/ACVS PURELAX POWDER PACKET N/ACVS RINGWORM 1% CREAM N/ACVS SENNA LAXATIVE 8.6 MG TAB N/ACVS SKIN TREATMENT BODY LOTION N/ACVS SMOOTH ANTACID 750 MG CHEW N/ACVS SPECTRAVITE ADULT 50 PLUS N/ACVS SPECTRAVITE ADVANCED TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CVS SPECTRAVITE MEN'S TABLET N/ACVS SPECTRAVITE SENIOR TABLET N/ACVS SPECTRAVITE ULTRA MEN TAB N/ACVS SPECTRAVITE ULTRA MEN'S TB N/ACVS SPECTRAVITE ULTRA WOMEN TB N/ACVS SPECTRAVITE WOMEN'S TABLET N/ACVS STOMACH RELF 525 MG/30 ML N/ACVS STOMACH RELIEF MAX STR LIQ N/ACVS STOOL SOFTENER 100 MG CAP N/ACVS STOOL SOFTENER 100 MG SFTG N/ACVS THERAPEUTIC SHAMPOO N/ACVS THERAPEUTIC SHAMPOO 0.5% N/ACVS THIN 26G LANCETS N/ACVS TUSSIN 100 MG/5 ML LIQUID N/ACVS TUSSIN CF COUGH-COLD SYRUP N/ACVS TUSSIN CF MAX LIQUID N/ACVS TUSSIN DM LIQUID N/ACVS ULTRA THIN 30G LANCETS N/ACVS VIT D3 1;000 UNIT GUMMIES N/ACVS VIT D3 10;000 UNIT SOFTGEL N/ACVS VITAMIN B-6 100 MG TABLET N/ACVS VITAMIN D3 1;000 UNIT SFGL N/ACVS VITAMIN D3 5;000 UNIT SFGL N/ACVS WART REMOVER 17% LIQUID N/ACYANOCOBALAMIN 1;000 MCG/ML N/ACYANOCOBALAMIN 10;000 MCG/10 N/ACYANOCOBALAMIN 30;000 MCG/30 N/ACYANOCOBALAMIN POWDER N/ACYCLAFEM 1-35-28 TABLET N/ACYCLAFEM 7-7-7-28 TABLET N/ACYCLOBENZAPRINE 10 MG TABLET N/ACYCLOBENZAPRINE 5 MG TABLET N/ACYCLOBENZAPRINE HCL POWDER N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

CYCLOPENTOLATE HCL 2% DROPS N/ACYCLOSPORINE 100 MG CAPSULE N/ACYCLOSPORINE 25 MG CAPSULE N/ACYCLOSPORINE MODIFIED 100 MG N/ACYCLOSPORINE MODIFIED 100MG/ML N/ACYCLOSPORINE MODIFIED 25 MG N/ACYCLOSPORINE MODIFIED 50 MG N/ACYPROHEPTADINE 2 MG/5 ML SOLN N/ACYPROHEPTADINE 2 MG/5 ML SYRUP N/ACYPROHEPTADINE 4 MG TABLET N/ACYPROHEPTADINE 4 MG/10 ML SYRP N/ACYRED 28 DAY TABLET N/AD3-2000 UNIT SOFTGEL N/AD3-50 50;000 UNIT CAPSULE N/ADAILY MULTI VITAMIN-IRON TAB N/ADAILY MULTIPLE TABLET N/ADAILY MULTIPLE VITAMIN TABLET N/ADAILY MULTIVITAMIN-IRON TABLET N/ADAILY MULTIVIT-MINERALS TAB N/ADAILY VITAMIN + IRON TABLET N/ADAILY VITAMIN FORMULA TABLET N/ADAILY VITAMIN FORMULA-IRON TAB N/ADAILY VITE WITH IRON TABLET N/ADANAZOL 100 MG CAPSULE N/ADANAZOL 200 MG CAPSULE N/ADANAZOL 50 MG CAPSULE N/ADANAZOL POWDER N/ADANTROLENE SODIUM 100 MG CAP N/ADANTROLENE SODIUM 25 MG CAP N/ADANTROLENE SODIUM 50 MG CAP N/ADAPSONE 100 MG TABLET N/ADAPSONE 25 MG TABLET N/ADARAPRIM 25 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

DASETTA 1-35-28 TABLET N/ADASETTA 7/7/7-28 TABLET N/ADAYSEE 0.15-0.03-0.01 MG TAB N/ADEBLITANE 0.35 MG TABLET N/ADECARA 50;000 UNIT SOFTGEL N/ADELSTRIGO 100-300-300 MG TAB N/ADELSYM COUGH+CHEST CNGST DM LQ N/ADELTA D3 400 UNIT TABLET N/ADEMECLOCYCLINE 150 MG TABLET N/ADEMECLOCYCLINE 300 MG TABLET N/ADENAVIR 1% CREAM N/ADERMACERIN CREAM N/ADERMAPHOR OINTMENT N/ADERMAREST ECZEMA 1% LOTION N/ADESCOVY 200-25 MG TABLET N/ADESGEN DM LIQUID N/ADESGEN PEDIATRIC DROPS N/ADESMOPRESSIN 0.01% SOLUTION N/ADESMOPRESSIN 0.01% SPRAY N/ADESMOPRESSIN 10 MCG/0.1 ML SPR N/ADESMOPRESSIN ACETATE 0.1 MG TB N/ADESMOPRESSIN ACETATE 0.2 MG TB N/ADESOGEST-ETH ESTRA 0.15-0.03MG N/ADESOGESTR-ETH ESTRAD ETH ESTRA N/ADESONIDE 0.05% CREAM N/ADESONIDE 0.05% LOTION N/ADESONIDE 0.05% OINTMENT N/ADESONIDE MICRONIZED POWDER N/ADESOXIMETASONE 0.05% CREAM N/ADESOXIMETASONE 0.05% GEL N/ADESOXIMETASONE 0.05% OINTMENT N/ADESOXIMETASONE 0.25% CREAM N/ADESOXIMETASONE 0.25% OINTMENT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

DESPEC DM SYRUP N/ADESPEC EDA COUGH & COLD DROPS N/ADEX4 GLUCOSE 4 GM TABLET CHEW N/ADEX4 GLUCOSE TAB POUCH PACK N/ADEX4 QUICK DISSOLVE TAB CHEW N/ADEXAMETHASONE 0.1% EYE DROP N/ADEXAMETHASONE 0.5 MG TABLET N/ADEXAMETHASONE 0.5 MG/5 ML ELX N/ADEXAMETHASONE 0.5 MG/5 ML LIQ N/ADEXAMETHASONE 0.75 MG TABLET N/ADEXAMETHASONE 1 MG TABLET N/ADEXAMETHASONE 1.5 MG TABLET N/ADEXAMETHASONE 120 MG/30 ML VL N/ADEXAMETHASONE 2 MG TABLET N/ADEXAMETHASONE 20 MG/5 ML VIAL N/ADEXAMETHASONE 4 MG TABLET N/ADEXAMETHASONE 4 MG/ML SYRINGE N/ADEXAMETHASONE 4 MG/ML VIAL N/ADEXAMETHASONE 6 MG TABLET N/ADEXAMETHASONE MICRONIZED POWD N/ADEXAMETHASONE SOD PH POWDER N/ADIABETES HEALTH FORMULA CAPLET N/ADIABETIC TUSSIN DM LIQUID N/ADIABETIC TUSSIN EX LIQUID N/ADIALYVITE 800-ULTRA D TABLET N/ADIALYVITE VIT D3 50;000 UNIT N/ADIALYVITE VITAMIN D 5;000 UNIT N/ADIAMODE 2 MG TABLET N/ADIARRHEA RELIEF 262 MG/15 ML N/ADIARRHEA RELIEF SUSPENSION N/ADIASTIX REAGENT STRIPS N/ADICLEGIS DR 10-10 MG TABLET N/ADICLOFENAC 0.1% EYE DROPS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

DICLOFENAC POT 50 MG TABLET N/ADICLOFENAC SOD DR 25 MG TAB N/ADICLOFENAC SOD DR 50 MG TAB N/ADICLOFENAC SOD DR 75 MG TAB N/ADICLOFENAC SOD EC 25 MG TAB N/ADICLOFENAC SOD EC 50 MG TAB N/ADICLOFENAC SOD EC 75 MG TAB N/ADICLOFENAC SOD ER 100 MG TAB N/ADICLOXACILLIN 250 MG CAPSULE N/ADICLOXACILLIN 500 MG CAPSULE N/ADICYCLOMINE 10 MG CAPSULE N/ADICYCLOMINE 10 MG/5 ML SOLN N/ADICYCLOMINE 20 MG TABLET N/ADIDANOSINE DR 250 MG CAPSULE N/ADIDANOSINE DR 400 MG CAPSULE N/ADIFLORASONE 0.05% CREAM N/ADIFLORASONE 0.05% OINTMENT N/ADIFLUNISAL 500 MG TABLET N/ADIGITEK 125 MCG TABLET N/ADIGITEK 250 MCG TABLET N/ADIGOX 125 MCG TABLET N/ADIGOX 250 MCG TABLET N/ADIGOXIN 0.05 MG/ML SOLUTION N/ADIGOXIN 0.125 MG TABLET N/ADIGOXIN 0.25 MG TABLET N/ADIGOXIN 125 MCG TABLET N/ADIGOXIN 250 MCG TABLET N/ADIHYDROERGOTAMINE 4 MG/ML SPRY N/ADIHYDROERGOTAMINE POWDER N/ADILANTIN 30 MG CAPSULE N/ADILT XR 120 MG CAPSULE N/ADILT XR 180 MG CAPSULE N/ADILT XR 240 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

DILTIAZEM 120 MG TABLET N/ADILTIAZEM 12HR ER 120 MG CAP N/ADILTIAZEM 12HR ER 60 MG CAP N/ADILTIAZEM 12HR ER 90 MG CAP N/ADILTIAZEM 24H ER(CD) 120 MG CP N/ADILTIAZEM 24H ER(CD) 180 MG CP N/ADILTIAZEM 24H ER(CD) 240 MG CP N/ADILTIAZEM 24H ER(CD) 300 MG CP N/ADILTIAZEM 24H ER(CD) 360 MG CP N/ADILTIAZEM 24HR ER 120 MG CAP N/ADILTIAZEM 24HR ER 180 MG CAP N/ADILTIAZEM 24HR ER 240 MG CAP N/ADILTIAZEM 24HR ER 300 MG CAP N/ADILTIAZEM 24HR ER 360 MG CAP N/ADILTIAZEM 24HR ER 420 MG CAP N/ADILTIAZEM 30 MG TABLET N/ADILTIAZEM 60 MG TABLET N/ADILTIAZEM 90 MG TABLET N/ADINO-LIFE IRON-ZINC TAB CHEW N/ADIPHEDRYL 12.5 MG/5 ML ELIXIR N/ADIPHEDRYL ALLERGY CAPSULE N/ADIPHENHIST 25 MG CAPSULE N/ADIPHENHYDRAMINE 12.5 MG/5 ML N/ADIPHENHYDRAMINE 25 MG CAPLET N/ADIPHENHYDRAMINE 25 MG CAPSULE N/ADIPHENHYDRAMINE 25 MG TABLET N/ADIPHENHYDRAMINE 25 MG/10 ML N/ADIPHENHYDRAMINE 50 MG CAPSULE N/ADIPHENHYDRAMINE HCL POWDER N/ADIPHENOXYLAT-ATROP 2.5-0.025/5 N/ADIPHENOXYLATE-ATROP 2.5-0.025 N/ADIPYRIDAMOLE 25 MG TABLET N/ADIPYRIDAMOLE 50 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

DIPYRIDAMOLE 75 MG TABLET N/ADISOPYRAMIDE 100 MG CAPSULE N/ADISOPYRAMIDE 150 MG CAPSULE N/ADIURIL 250 MG/5 ML ORAL SUSP N/ADOCUPRENE 100 MG TABLET N/ADOCUSATE SODIUM 100 MG CAPSULE N/ADOCUSATE SODIUM 100 MG SOFTGEL N/ADOCUSATE SODIUM 100 MG TABLET N/ADOCUSIL 100 MG SOFTGEL N/ADOK 100 MG SOFTGEL N/ADOK 100 MG TABLET N/ADOMETUSS-DMX LIQUID N/ADOPTELET (10 TAB PK) 20 MG TAB N/ADOPTELET (15 TAB PK) 20 MG TAB N/ADOPTELET (30 TAB PK) 20 MG TAB N/ADORZOLAMIDE HCL 2% EYE DROPS N/ADORZOLAMIDE-TIMOLOL EYE DROPS N/ADOVATO 50-300 MG TABLET N/ADOXAZOSIN MESYLATE 1 MG TAB N/ADOXAZOSIN MESYLATE 2 MG TAB N/ADOXAZOSIN MESYLATE 4 MG TAB N/ADOXAZOSIN MESYLATE 8 MG TAB N/ADOXERCALCIFEROL 0.5 MCG CAP N/ADOXERCALCIFEROL 1 MCG CAPSULE N/ADOXERCALCIFEROL 2.5 MCG CAP N/ADOXYCYCLINE HYC DR 100 MG TAB N/ADOXYCYCLINE HYC DR 150 MG TAB N/ADOXYCYCLINE HYC DR 75 MG TAB N/ADOXYCYCLINE HYCLATE 20 MG TAB N/ADOXYCYCLINE HYCLATE POWDER N/ADOXYCYCLINE MONO 100 MG CAP N/ADOXYCYCLINE MONO 100 MG TABLET N/ADOXYCYCLINE MONO 150 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

DOXYCYCLINE MONO 50 MG CAP N/ADOXYCYCLINE MONO 50 MG TABLET N/ADOXYCYCLINE MONO 75 MG CAPSULE N/ADOXYCYCLINE MONO 75 MG TABLET N/ADOXYLAMINE-PYRIDOXINE 10-10 MG N/ADRAMAMINE LESS DROWSY 25 MG TB N/ADROPLET 30G LANCETS N/ADROPLET LANCING DEVICE N/ADROSP-EE-LEVOMEF 3-0.03-0.451 N/ADROSPIRENONE-EE 3-0.03 MG TAB N/ADROXIA 200 MG CAPSULE N/ADROXIA 300 MG CAPSULE N/ADROXIA 400 MG CAPSULE N/ADRUG MART GLUCOSE 4 GM TAB CHW N/ADRUG MART ULTRA COMFORT SYR N/ADULCOEASE 100 MG SOFTGEL N/ADULCOLAX SS 100 MG SOFTGEL N/ADURAVENT DM TABLET N/AE.E.S. 400 FILMTAB N/AEASIVENT HOLDING CHAMBER N/AEASIVENT MASK-LARGE N/AEASIVENT MASK-MEDIUM N/AEASIVENT MASK-SMALL N/AEASY COMFORT 0.3 ML SYRINGE N/AEASY COMFORT 0.5 ML 30GX1/2'' N/AEASY COMFORT 0.5 ML 31GX5/16'' N/AEASY COMFORT 0.5 ML SYRINGE N/AEASY COMFORT 1 ML 31GX5/16'' N/AEASY COMFORT 30G LANCETS N/AEASY COMFORT INSULIN 1 ML SYR N/AEASY COMFORT SYR 1 ML 30GX1/2'' N/AEASY MINI EJECT LANCING DEVICE N/AEASY TOUCH 0.3 ML SYR 30GX1/2'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EASY TOUCH 0.5 ML SYR 29GX1/2'' N/AEASY TOUCH 0.5 ML SYR 30GX1/2'' N/AEASY TOUCH 0.5 ML SYR 30GX5/16 N/AEASY TOUCH 1 ML SYR 27GX1/2'' N/AEASY TOUCH 1 ML SYR 29GX1/2'' N/AEASY TOUCH 1 ML SYR 30GX1/2'' N/AEASY TOUCH ALCOHOL 70% PADS N/AEASY TOUCH BUTTON 30G LANCETS N/AEASY TOUCH FLIPLOCK 3 ML 22GX1 N/AEASY TOUCH INSULIN 1ML 29GX1/2 N/AEASY TOUCH INSULIN 1ML 30GX1/2 N/AEASY TOUCH INSULIN SYR 0.3 ML N/AEASY TOUCH INSULIN SYR 0.5 ML N/AEASY TOUCH INSULIN SYR 1 ML N/AEASY TOUCH INSULN 1ML 29GX1/2'' N/AEASY TOUCH INSULN 1ML 30GX1/2'' N/AEASY TOUCH INSULN 1ML 30GX5/16 N/AEASY TOUCH INSULN 1ML 31GX5/16 N/AEASY TOUCH LANCING DEVICE N/AEASY TOUCH PRESSURE 30G LANCET N/AEASY TOUCH PULL-TOP 26G LANCET N/AEASY TOUCH PULL-TOP 28G LANCET N/AEASY TOUCH PULL-TOP 30G LANCET N/AEASY TOUCH PULL-TOP 32G LANCET N/AEASY TOUCH SAFETY 21G LANCETS N/AEASY TOUCH SAFETY 23G LANCETS N/AEASY TOUCH SAFETY 26G LANCETS N/AEASY TOUCH SAFETY 28G LANCETS N/AEASY TOUCH SAFETY 32G LANCETS N/AEASY TOUCH SHEATH 3 ML 22GX1'' N/AEASY TOUCH SYRINGE 3 ML 22GX1'' N/AEASY TOUCH TWIST 26G LANCETS N/AEASY TOUCH TWIST 28G LANCETS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EASY TOUCH TWIST 30G LANCETS N/AEASY TOUCH TWIST 32G LANCETS N/AEASY TOUCH TWIST 33G LANCETS N/AEASY TWIST & CAP 28G LANCETS N/AEASY-TOUCH INS 1 ML 31GX5/16'' N/AEC-NAPROXEN DR 375 MG TABLET N/AEC-NAPROXEN DR 500 MG TABLET N/AECONAZOLE NITRATE 1% CREAM N/AECOTRIN EC 81 MG TABLET N/AECPIRIN EC 325 MG TABLET N/AED-APAP 160 MG/5 ML LIQUID N/AED-SPAZ 0.125 MG ODT N/AEDURANT 25 MG TABLET N/AEEMT DS 1.25-2.5 MG TABLET N/AEEMT HS 0.625-1.25 MG TABLET N/AEFAVIRENZ 200 MG CAPSULE N/AEFAVIRENZ 50 MG CAPSULE N/AEFAVIRENZ 600 MG TABLET N/AEFFER-K 25 MEQ TABLET EFF N/AELIDEL 1% CREAM N/AELIGARD 22.5 MG SYRINGE KIT N/AELIGARD 30 MG SYRINGE KIT N/AELIGARD 45 MG SYRINGE KIT N/AELIGARD 7.5 MG SYRINGE KIT N/AELINEST-28 TABLET N/AELIQUIS 2.5 MG TABLET N/AELIQUIS 5 MG TABLET N/AELITE-OB CAPLET N/AELLA 30 MG TABLET N/AELMIRON 100 MG CAPSULE N/AELURYNG VAGINAL RING N/AEMBRACE 30G LANCETS N/AEMEND 40 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EMEND 80 MG CAPSULE N/AEMEND TRIPACK N/AEMOQUETTE 28 DAY TABLET N/AEMPTY GELATIN CAP N/AEMTRIVA 10 MG/ML SOLUTION N/AEMTRIVA 200 MG CAPSULE N/AENALAPRIL MALEATE 10 MG TAB N/AENALAPRIL MALEATE 2.5 MG TAB N/AENALAPRIL MALEATE 20 MG TAB N/AENALAPRIL MALEATE 5 MG TABLET N/AENALAPRIL-HCTZ 10-25 MG TABLET N/AENALAPRIL-HCTZ 5-12.5 MG TAB N/AENBREL 25 MG/0.5 ML SYRINGE N/AENBREL 50 MG/ML MINI CARTRIDGE N/AENBREL 50 MG/ML SURECLICK N/AENBREL 50 MG/ML SYRINGE N/AENDOCET 10-325 MG TABLET N/AENDOCET 2.5-325 MG TABLET N/AENDOCET 5-325 TABLET N/AENDOCET 7.5-325 MG TABLET N/AENFAMIL WATER NURSETTE LIQUID N/AENGERIX-B 20 MCG/ML SYRN N/AENGERIX-B 20 MCG/ML VIAL N/AENGLISH TOFFEE FLAVOR LIQUID N/AENOXAPARIN 100 MG/ML SYRINGE N/AENOXAPARIN 120 MG/0.8 ML SYR N/AENOXAPARIN 150 MG/ML SYRINGE N/AENOXAPARIN 30 MG/0.3 ML SYR N/AENOXAPARIN 300 MG/3 ML VIAL N/AENOXAPARIN 40 MG/0.4 ML SYR N/AENOXAPARIN 60 MG/0.6 ML SYR N/AENOXAPARIN 80 MG/0.8 ML SYR N/AENPRESSE-28 TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ENSKYCE 28 TABLET N/AENTACAPONE 200 MG TABLET N/AENTECAVIR 0.5 MG TABLET N/AENTECAVIR 1 MG TABLET N/AENTRESTO 24 MG-26 MG TABLET N/AENTRESTO 49 MG-51 MG TABLET N/AENTRESTO 97 MG-103 MG TABLET N/AENULOSE 10 GM/15 ML SOLUTION N/AEPINASTINE HCL 0.05% EYE DROPS N/AEPINEPHRINE 0.15 MG AUTO-INJCT N/AEPINEPHRINE 0.3 MG AUTO-INJECT N/AEPIVIR 10 MG/ML ORAL SOLN N/AEPIVIR 150 MG TABLET N/AEPIVIR 300 MG TABLET N/AEPIVIR HBV 25 MG/5 ML SOLN N/AEPOGEN 10;000 UNITS/ML VIAL N/AEPOGEN 2;000 UNITS/ML VIAL N/AEPOGEN 20;000 UNITS/ML VIAL N/AEPOGEN 3;000 UNITS/ML VIAL N/AEPOGEN 4;000 UNITS/ML VIAL N/AEPOPROSTENOL SODIUM 0.5 MG VL N/AEPOPROSTENOL SODIUM 1.5 MG VL N/AEPZICOM TABLET N/AEQ ACETAMINOPHEN 500 MG CAPLET N/AEQ ACETAMINOPHEN 500 MG GELCAP N/AEQ ACETAMINOPHEN 500 MG TABLET N/AEQ ACID REDUCER 20 MG TABLET N/AEQ ACID REDUCER 200 MG TABLET N/AEQ ALLERGY (LORAT) 10 MG TAB N/AEQ ALLERGY RELIEF 1 MG/ML SOLN N/AEQ ALLERGY RELIEF 10 MG TABLET N/AEQ ALLERGY RELIEF 180 MG TAB N/AEQ ALLERGY RELIEF 25 MG CAP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EQ ALLERGY RELIEF 25 MG TABLET N/AEQ ALLERGY RELIEF 50 MCG SPRAY N/AEQ ANTACID EXTRA STR CHEW TAB N/AEQ ANTACID ULTRA STR TAB CHEW N/AEQ ANTI-DIARRHEAL 2 MG CAPLET N/AEQ ANTI-DIARRHEAL 2 MG SFTGEL N/AEQ ANTI-ITCH PLUS 1% CREAM N/AEQ ARTHRITIS PAIN ER 650 MG N/AEQ ASPIRIN 325 MG TABLET N/AEQ ASPIRIN EC 325 MG TABLET N/AEQ ASPIRIN EC 81 MG TABLET N/AEQ CALCIUM 600-VIT D3 400 TAB N/AEQ CALCIUM CITRATE-D TABLET N/AEQ CHILD ALLERGY 12.5 MG/5 ML N/AEQ CHILD ALLERGY RELF 1 MG/ML N/AEQ CHILD ALLERGY RELIEF SOLN N/AEQ CHILD IBUPROFEN 100 MG/5 ML N/AEQ CHILDREN'S COUGH LIQUID N/AEQ CHLD ACETAMINOPHEN 80 MG TB N/AEQ CHLORTABS 4 MG TABLET N/AEQ CLEARLAX POWDER N/AEQ COMPLETE MULTIVITAMIN TAB N/AEQ FIBER THERAPY 0.52 GRAM CAP N/AEQ HYDROCORTISONE 1% CREAM N/AEQ HYDROCORTISONE-ALOE 1% CRM N/AEQ IBUPROFEN 200 MG CAPLET N/AEQ IBUPROFEN 200 MG TABLET N/AEQ INF GAS RELIEF 20 MG/0.3 ML N/AEQ JOCK ITCH 1% CREAM N/AEQ LANSOPRAZOLE DR 15 MG CAP N/AEQ LICE KILLING SHAMPOO N/AEQ MICONAZOLE 2% VAGINAL CREAM N/AEQ MICONAZOLE 7 CREAM N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EQ MOTION SICKNESS 25 MG TAB N/AEQ MUCUS ER 600 MG TABLET N/AEQ NASAL 0.05% SPRAY N/AEQ NASAL ALLERGY 24HR SPRAY N/AEQ NATURAL LAXATIVE 8.6 MG TAB N/AEQ OMEPRAZOLE DR 20 MG TABLET N/AEQ OMEPRAZOLE MAG DR 20.6 MG N/AEQ ONE DAILY MEN'S TABLET N/AEQ ONE DAILY TABLET N/AEQ ONE DAILY WOMEN'S TABLET N/AEQ ORIGINAL NASAL SPRAY 0.05% N/AEQ PAIN RELIEF 500 MG/15 ML LQ N/AEQ PAIN RELIEVER 325 MG TABLET N/AEQ PAIN RELIEVER 500 MG CAPLET N/AEQ RESTORE TEARS 0.5% EYE DROP N/AEQ REVIVE PLUS 0.5% EYE DROPS N/AEQ STOMACH RELIEF 262 MG/15 ML N/AEQ STOOL SOFTENER 100 MG SFTGL N/AEQ TERBINAFINE 1% CREAM N/AEQ TRIPLE ANTIBIOTIC OINTMENT N/AEQ TUSSIN CF COUGH-COLD LIQUID N/AEQ TUSSIN CF LIQUID N/AEQ TUSSIN CF MAX M-S COLD LIQ N/AEQ TUSSIN DM COUGH-CHEST SYR N/AEQ VEGETABLE LAXATIVE TABLET N/AEQ VISION FORMULA TABLET N/AEQL 12HR NASAL SPRAY 0.05% N/AEQL ACETAMINOPHEN 500 MG CPLT N/AEQL ACETAMINOPHEN 500 MG GELCP N/AEQL ALL DAY ALLERGY 10 MG TAB N/AEQL ALL DAY ALLERGY-D TABLET N/AEQL ALLER-EASE 180 MG TABLET N/AEQL ALLERGY 25 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EQL ALLERGY 4 MG TABLET N/AEQL ALLERGY RELIEF 10 MG TAB N/AEQL ALLERGY RELIEF 25 MG CAP N/AEQL ALLERGY-CONGEST RLF ER TAB N/AEQL ALLERGY-CONGESTION 12H TAB N/AEQL ANTACID 500 MG CHEW TABLET N/AEQL ANTACID EXTRA STR CHEW TAB N/AEQL ANTACID ULTRA STR TAB CHEW N/AEQL ANTI-DIARRHEAL 2 MG CAPLET N/AEQL ANTIFUNGAL 1% TOP CREAM N/AEQL ANTI-ITCH 1% CREAM N/AEQL ANTI-ITCH 1% OINTMENT N/AEQL ARTHRIT PAIN RLF ER 650 MG N/AEQL ASPIRIN 325 MG TABLET N/AEQL ASPIRIN EC 325 MG TABLET N/AEQL ASPIRIN EC 81 MG TABLET N/AEQL ATHLETE'S FOOT 1% CREAM N/AEQL CALCIUM 600-VIT D3 800 TAB N/AEQL CALCIUM CITRATE-VIT D3 CPT N/AEQL CASTOR OIL N/AEQL CENTURY MATURE TABLET N/AEQL CHILD ALLERGY 12.5 MG/5 ML N/AEQL CHLD ALL DAY ALLER 1 MG/ML N/AEQL CHLD IBUPROFEN 100 MG/5 ML N/AEQL CLEARLAX POWDER N/AEQL EYE HEALTH PLUS LUTEIN TAB N/AEQL FIRST AID ANTIBIOTIC OINT N/AEQL FISH OIL 1;200 MG SOFTGEL N/AEQL FISH OIL EC 1;200 MG SFTGL N/AEQL FLUTICASONE PROP 50 MCG N/AEQL HEARTBURN PREVEN 20 MG TAB N/AEQL IBUPROFEN 200 MG CAPLET N/AEQL IBUPROFEN 200 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EQL INS SYR 1 ML 29GX1/2'' N/AEQL INSUL SYR 0.3 ML 31GX5/16'' N/AEQL INSUL SYR 0.5 ML 31GX5/16'' N/AEQL INSULIN 0.3 ML SYRINGE N/AEQL INSULIN 0.5 ML SYRINGE N/AEQL INSULIN 1 ML SYRINGE N/AEQL INSULIN SYR 1 ML 31GX5/16'' N/AEQL JR ACETAMINOPHEN 160MG TAB N/AEQL LANSOPRAZOLE DR 15 MG CAP N/AEQL LICE KILLING SHAMPOO N/AEQL MICRO THIN 33G LANCETS N/AEQL MOTION SICKNESS 25 MG TAB N/AEQL MUCUS ER 600 MG TABLET N/AEQL NASAL SPRAY 0.05% N/AEQL OMEGA-3 FISH OIL 1;000 MG N/AEQL OMEPRAZOLE DR 20 MG TABLET N/AEQL ONE DAILY MEN'S TABLET N/AEQL ONE DAILY WOMEN'S 50 PLUS N/AEQL PEN 8MM 31G X 5/16'' NEEDLE N/AEQL SENNA LAXATIVE 8.6 MG TAB N/AEQL SLEEP AID 25 MG TABLET N/AEQL STOMACH RELIEF LIQUID N/AEQL STOMACH RLF 262 MG/15 ML N/AEQL STOMACH RLF 525 MG/15 ML N/AEQL STOMACH RLF 525 MG/30 ML N/AEQL STOOL SOFTENER 100 MG SFGL N/AEQL SUPER B COMPLEX TABLET N/AEQL TUSSIN CF LIQUID N/AEQL TUSSIN CHEST CONGEST SYRUP N/AEQL TUSSIN DM COUGH-CHEST SYR N/AEQL TUSSIN MUCUS-CHEST CONGEST N/AEQL VITAMIN B-6 100 MG TABLET N/AEQL VITAMIN D3 1;000 UNIT SFGL N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

EQL VITAMIN D3 2;000 UNIT SFGL N/AEQL VITAMIN D3 400 UNIT SFTGL N/AEQL VITAMIN D3 5;000 UNIT SFGL N/AERGOCALCIFEROL 200 MCG/ML DROP N/AERGOCALCIFEROL 8;000 UNITS/ML N/AERGOCALCIFEROL POWDER N/AERGOLOID MESYLATES 1 MG TAB N/AERGOMAR 2 MG TABLET SL N/AERGOTAMINE TARTRATE POWDER N/AERRIN 0.35 MG TABLET N/AERY 2% PADS N/AERYPED 400 MG/5 ML SUSPENSION N/AERY-TAB DR 250 MG TABLET N/AERY-TAB DR 333 MG TABLET N/AERY-TAB DR 500 MG TABLET N/AERYTHROCIN 250 MG FILMTAB N/AERYTHROMYCIN 0.5% EYE OINTMENT N/AERYTHROMYCIN 2% GEL N/AERYTHROMYCIN 2% SOLUTION N/AERYTHROMYCIN 200 MG/5 ML SUSP N/AERYTHROMYCIN 250 MG FILMTAB N/AERYTHROMYCIN 400 MG/5 ML SUSP N/AERYTHROMYCIN 500 MG FILMTAB N/AERYTHROMYCIN DR 250 MG CAP N/AERYTHROMYCIN DR 500 MG TABLET N/AERYTHROMYCIN E.S. POWDER N/AERYTHROMYCIN ES 400 MG TAB N/AERYTHROMYCIN POWDER N/AESGIC CAPSULE N/AESSENTIA TABLET N/AESSENTIAL BALANCE TABLET N/AESSENTIAL DAILY TABLET N/AESSENTIAL MAN 50+ TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ESSENTIAL MAN TABLET N/AESSENTIAL WOMAN 50+ TABLET N/AESTARYLLA 0.25-0.035 MG TABLET N/AESTRACE 0.01% CREAM N/AESTRADIOL 0.01% CREAM N/AESTRADIOL 0.0375 MG/DAY PATCH N/AESTRADIOL 0.06 MG/DAY PATCH N/AESTRADIOL 0.075 MG/DAY PATCH N/AESTRADIOL 0.5 MG TABLET N/AESTRADIOL 1 MG TABLET N/AESTRADIOL 2 MG TABLET N/AESTRADIOL MICRONIZED POWDER N/AESTRADIOL POWDER N/AESTRADIOL TDS 0.025 MG/DAY N/AESTRADIOL TDS 0.0375 MG/DAY N/AESTRADIOL TDS 0.05 MG/DAY N/AESTRADIOL TDS 0.06 MG/DAY N/AESTRADIOL TDS 0.075 MG/DAY N/AESTRADIOL TDS 0.1 MG/DAY N/AESTROGEN-METHYLTESTOS F.S. TAB N/AESTROGEN-METHYLTESTOS H.S. TAB N/AETHAMBUTOL HCL 100 MG TABLET N/AETHAMBUTOL HCL 400 MG TABLET N/AETHOSUXIMIDE 250 MG CAPSULE N/AETHOSUXIMIDE 250 MG/5 ML SOLN N/AETHYL OLEATE LIQUID N/AETIDRONATE DISODIUM 200 MG TAB N/AETODOLAC 200 MG CAPSULE N/AETODOLAC 300 MG CAPSULE N/AETODOLAC 400 MG TABLET N/AETODOLAC 500 MG TABLET N/AETODOLAC ER 400 MG TABLET N/AETODOLAC ER 500 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ETODOLAC ER 600 MG TABLET N/AETONOGESTREL-EE VAGINAL RING N/AEUCALYPTOL LIQUID N/AEUCRISA 2% OINTMENT N/AEUFLEXXA 20 MG/2 ML SYRINGE N/AEVAC-U-GEN 8.6 MG TABLET N/AEVOTAZ 300 MG-150 MG TABLET N/AEXEL INS SYR U100 1 ML 28GX1/2 N/AEXEL SYRINGE 22GX1'' 3 ML N/AEXEL U100 0.3 ML 29GX1/2'' N/AEXEL U100 0.3 ML 30GX5/16'' N/AEXEL U100 0.5 ML 28GX1/2'' N/AEXEL U100 0.5 ML 29GX1/2'' N/AEXEL U100 0.5 ML 30GX5/16'' N/AEXEL U100 1 ML 30GX5/16'' N/AEXEL U100 INS SYR 1 ML 29GX1/2 N/AEXEMESTANE 25 MG TABLET N/AEX-LAX CHOCOLATE N/AEXTAVIA 0.3 MG KIT N/AEYE ITCH RELIEF 0.025% DROPS N/AEYEPROTECT TABLET N/AE-Z JECT COLORED LANCETS N/AE-Z JECT LANCETS N/AE-Z PULL & CLICK LANCING DEV N/AEZ SMART 28G LANCETS N/AEZETIMIBE 10 MG TABLET N/AEZETIMIBE-SIMVASTATIN 10-10 MG N/AEZETIMIBE-SIMVASTATIN 10-20 MG N/AEZETIMIBE-SIMVASTATIN 10-40 MG N/AEZETIMIBE-SIMVASTATIN 10-80 MG N/AE-ZJECT COLOR 32G LANCETS N/AE-ZJECT COLOR 33G LANCETS N/AE-ZJECT SUPER THIN 30G LANCETS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

E-ZJECT THIN LANCETS N/AFA-8 CAPSULES N/AFALMINA-28 TABLET N/AFAMCICLOVIR 125 MG TABLET N/AFAMCICLOVIR 250 MG TABLET N/AFAMCICLOVIR 500 MG TABLET N/AFAMOTIDINE 20 MG TABLET N/AFAMOTIDINE 40 MG TABLET N/AFANTASY CONDOM N/AFEBUXOSTAT 40 MG TABLET N/AFEBUXOSTAT 80 MG TABLET N/AFELODIPINE ER 10 MG TABLET N/AFELODIPINE ER 2.5 MG TABLET N/AFELODIPINE ER 5 MG TABLET N/AFENOFIBRATE 134 MG CAPSULE N/AFENOFIBRATE 145 MG TABLET N/AFENOFIBRATE 160 MG TABLET N/AFENOFIBRATE 200 MG CAPSULE N/AFENOFIBRATE 48 MG TABLET N/AFENOFIBRATE 54 MG TABLET N/AFENOFIBRATE 67 MG CAPSULE N/AFENOFIBRIC ACID DR 135 MG CAP N/AFENOFIBRIC ACID DR 45 MG CAP N/AFENOPROFEN 600 MG TABLET N/AFENTANYL 100 MCG/HR PATCH N/AFENTANYL 12 MCG/HR PATCH N/AFENTANYL 25 MCG/HR PATCH N/AFENTANYL 37.5 MCG/HR PATCH N/AFENTANYL 50 MCG/HR PATCH N/AFENTANYL 62.5 MCG/HR PATCH N/AFENTANYL 75 MCG/HR PATCH N/AFENTANYL 87.5 MCG/HR PATCH N/AFEOSOL 65 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

FEROSUL 325 MG TABLET N/AFERRO-TIME 325 MG TABLET N/AFERROUS SULF 15 MG IRON/ML DRP N/AFERROUS SULF 220 MG/5 ML ELIX N/AFERROUS SULF 300 MG/5 ML LIQ N/AFERROUS SULF 44 MG IRON/5ML LQ N/AFERROUS SULF EC 325 MG TABLET N/AFERROUS SULFATE 325 MG TABLET N/AFERROUSUL 325 MG TABLET N/AFEXOFENADINE HCL 180 MG TABLET N/AFEXOFENADINE HCL 30 MG/5 ML N/AFEXOFENADINE HCL 60 MG TABLET N/AFEXOFENADINE-PSE ER 60-120 TAB N/AFIBER 0.52 GRAM CAPSULE N/AFIBER THERAPY POWDER N/AFIFTY50 ALCOHOL PREP PADS N/AFIFTY50 INS 0.3 ML 31GX5/16'' N/AFIFTY50 INS 0.5 ML 31GX5/16'' N/AFIFTY50 INS SYR 1 ML 31GX5/16'' N/AFIFTY50 LANCING DEVICE N/AFIFTY50 SAFETY SEAL 30G LANCET N/AFIFTY50 SAFETY SEAL 32G LANCET N/AFIFTY50 UNILET 33G LANCETS N/AFINACEA 15% GEL N/AFINASTERIDE 5 MG TABLET N/AFINE 30 UNIVERSAL 30G LANCETS N/AFINGERSTIX LANCETS N/AFIRMAGON 2 X 120 MG KIT N/AFIRMAGON 80 MG KIT N/AFIRST AID ANTIBIOTIC OINTMENT N/AFIRST-LANSOPRAZOLE 3 MG/ML N/AFIRST-OMEPRAZOLE 2 MG/ML SUSP N/AFISH OIL 1;000 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

FISH OIL 1;000 MG SOFTGEL N/AFISH OIL 1;200 MG FISH OIL N/AFISH OIL 1;400 MG SOFTGEL N/AFISH OIL CONC 1;000 MG SOFTGEL N/AFISH OIL CONCENTRATE SOFTGEL N/AFISH OIL DR 1;000 MG SOFTGEL N/AFISH OIL EC 1;000 MG SOFTGEL N/AFISH OIL EC 1;200 MG SOFTGEL N/AFISH OIL PEARLS SOFTGEL N/AFLAVOR BLEND 2 IN 1 SUSPENSION N/AFLAVOR PLUS SUSP N/AFLAVOR SWEET SYRUP N/AFLAVORX FLAVORING LIQUID N/AFLAVOXATE HCL 100 MG TABLET N/AFLECAINIDE ACETATE 100 MG TAB N/AFLECAINIDE ACETATE 150 MG TAB N/AFLECAINIDE ACETATE 50 MG TAB N/AFLEET BISACODYL 10 MG ENEMA N/AFLEXICHAMBER N/AFLINTSTONES WITH IRON TAB CHEW N/AFLONASE ALLERGY RLF 50 MCG SPR N/AFLOVENT HFA 110 MCG INHALER N/AFLOVENT HFA 220 MCG INHALER N/AFLOVENT HFA 44 MCG INHALER N/AFLUAD 2019-2020 SYRINGE N/AFLUARIX QUAD 2019-2020 SYRINGE N/AFLUBLOK QUAD 2019-2020 SYRINGE N/AFLUCELVAX QUAD 2019-2020 SYR N/AFLUCELVAX QUAD 2019-2020 VIAL N/AFLUCONAZOLE 10 MG/ML SUSP N/AFLUCONAZOLE 100 MG TABLET N/AFLUCONAZOLE 150 MG TABLET N/AFLUCONAZOLE 200 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

FLUCONAZOLE 40 MG/ML SUSP N/AFLUCONAZOLE 50 MG TABLET N/AFLUDROCORTISONE 0.1 MG TABLET N/AFLUDROCORTISONE ACETATE POWDER N/AFLULAVAL QUAD 2019-2020 SYR N/AFLULAVAL QUAD 2019-2020 VIAL N/AFLUNISOLIDE 0.025% SPRAY N/AFLUOCINOLONE 0.01% BODY OIL N/AFLUOCINOLONE 0.01% CREAM N/AFLUOCINOLONE 0.01% SCALP OIL N/AFLUOCINOLONE 0.01% SOLUTION N/AFLUOCINOLONE 0.025% CREAM N/AFLUOCINOLONE 0.025% OINTMENT N/AFLUOCINOLONE ACETONIDE POWDER N/AFLUOCINONIDE 0.05% CREAM N/AFLUOCINONIDE 0.05% GEL N/AFLUOCINONIDE 0.05% OINTMENT N/AFLUOCINONIDE 0.05% SOLUTION N/AFLUOCINONIDE 0.1% CREAM N/AFLUOCINONIDE MICRONIZED POWDER N/AFLUOCINONIDE-E 0.05% CREAM N/AFLUORABON 0.25 MG/0.6 ML DROPS N/AFLUORIDE 0.25 MG TABLET CHEW N/AFLUORIDE 0.5 MG TABLET CHEW N/AFLUORIDE 1 MG TABLET CHEWABLE N/AFLUORITAB 0.5 MG TABLET CHEW N/AFLUORITAB 1 MG TABLET CHEW N/AFLUOROMETHOLONE 0.1% DROPS N/AFLUOROPLEX 1% CREAM N/AFLUOROURACIL 0.5% CREAM N/AFLUOROURACIL 2% TOPICAL SOLN N/AFLUOROURACIL 5% CREAM N/AFLUOROURACIL 5% TOPICAL SOLN N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

FLURBIPROFEN 0.03% EYE DROP N/AFLURBIPROFEN 100 MG TABLET N/AFLURBIPROFEN POWDER N/AFLUTAMIDE 125 MG CAPSULE N/AFLUTICASONE PROP 0.005% OINT N/AFLUTICASONE PROP 0.05% CREAM N/AFLUTICASONE PROP 0.05% LOTION N/AFLUTICASONE PROP 50 MCG SPRAY N/AFLUTICASONE-SALMETEROL 100-50 N/AFLUTICASONE-SALMETEROL 113-14 N/AFLUTICASONE-SALMETEROL 232-14 N/AFLUTICASONE-SALMETEROL 250-50 N/AFLUTICASONE-SALMETEROL 500-50 N/AFLUTICASONE-SALMETEROL 55-14 N/AFLUZONE HIGH-DOSE 2019-20 SYR N/AFLUZONE QUAD 2019-2020 SYRINGE N/AFLUZONE QUAD 2019-2020 VIAL N/AFLUZONE QUAD PEDI 2019-20 SYR N/AFOLIC ACID 0.4 MG TABLET N/AFOLIC ACID 0.8 MG TABLET N/AFOLIC ACID 1 MG TABLET N/AFOLIC ACID 1;000 MCG TABLET N/AFOLIC ACID 400 MCG TABLET N/AFOLIC ACID 5 MG/ML VIAL N/AFOLIC ACID 50 MG/10 ML VIAL N/AFOLIC ACID 800 MCG TABLET N/AFOLIC ACID POWDER N/AFONDAPARINUX 10 MG/0.8 ML SYR N/AFONDAPARINUX 2.5 MG/0.5 ML SYR N/AFONDAPARINUX 5 MG/0.4 ML SYR N/AFONDAPARINUX 7.5 MG/0.6 ML SYR N/AFORA 30G LANCETS N/AFORA LANCING DEVICE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

FORACARE 30G LANCETS N/AFOSAMPRENAVIR 700 MG TABLET N/AFOSINOPRIL SODIUM 10 MG TAB N/AFOSINOPRIL SODIUM 20 MG TAB N/AFOSINOPRIL SODIUM 40 MG TAB N/AFOSINOPRIL-HCTZ 10-12.5 MG TAB N/AFOSINOPRIL-HCTZ 20-12.5 MG TAB N/AFRAGMIN 10;000 UNIT/ML SYRINGE N/AFRAGMIN 12;500 UNIT/0.5 ML SYR N/AFRAGMIN 15;000 UNIT/0.6 ML SYR N/AFRAGMIN 18;000 UNIT/0.72 ML N/AFRAGMIN 2;500 UNIT/0.2 ML SYR N/AFRAGMIN 5;000 UNIT/0.2 ML SYR N/AFRAGMIN 7;500 UNIT/0.3 ML SYR N/AFRAGMIN 95;000 UNIT/3.8 ML VL N/AFREEDAVITE TABLET N/AFREESTYLE 28G LANCETS N/AFREESTYLE PREC 0.5 ML 30GX5/16 N/AFREESTYLE PREC 0.5 ML 31GX5/16 N/AFREESTYLE PREC 1 ML 30GX5/16'' N/AFREESTYLE PREC 1 ML 31GX5/16'' N/AFREESTYLE UNISTIK 2 LANCETS N/AFUNGI CURE INTENSIVE 1% SPRAY N/AFUROSEMIDE 10 MG/ML SOLUTION N/AFUROSEMIDE 20 MG TABLET N/AFUROSEMIDE 40 MG TABLET N/AFUROSEMIDE 40 MG/5 ML SOLN N/AFUROSEMIDE 80 MG TABLET N/AFUROSEMIDE POWDER N/AFUZEON 90 MG VIAL N/AGALANTAMINE 4 MG/ML ORAL SOLN N/AGALANTAMINE ER 16 MG CAPSULE N/AGALANTAMINE ER 24 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GALANTAMINE ER 8 MG CAPSULE N/AGALANTAMINE HBR 12 MG TABLET N/AGALANTAMINE HBR 4 MG TABLET N/AGALANTAMINE HBR 8 MG TABLET N/AGARDASIL 9 SYRINGE N/AGARDASIL 9 VIAL N/AGAS RELIEF 20 MG/0.3 ML DROPS N/AGAS RELIEF 40 MG/0.6 ML DROPS N/AGAS RELIEF 80 MG TABLET CHEW N/AGAS RELIEF 80 TABLET CHEW N/AGAS RELIEF DROPS N/AGAS RELIEF DROPS 20 MG/0.3 ML N/AGATIFLOXACIN 0.5% EYE DROPS N/AGAVILAX POWDER N/AGAVILYTE-C SOLUTION N/AGAVILYTE-G SOLUTION N/AGAVILYTE-N SOLUTION N/AGE LANCING DEVICE N/AGELATIN 10GR CAPSULE N/AGELATIN 600 MG CAPSULE N/AGELATIN 650 MG CAPSULE N/AGEL-ONE 30 MG/3 ML SYRINGE N/AGEMFIBROZIL 600 MG TABLET N/AGEMFIBROZIL POWDER N/AGENERLAC 10 GM/15 ML SOLUTION N/AGENGRAF 100 MG CAPSULE N/AGENGRAF 100 MG/ML SOLUTION N/AGENGRAF 25 MG CAPSULE N/AGENTAK 0.3 % EYE OINTMENT N/AGENTAMICIN 0.1% CREAM N/AGENTAMICIN 0.1% OINTMENT N/AGENTAMICIN 0.3% EYE DROP N/AGENTAMICIN 3 MG/ML EYE DROP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GENTAMICIN SULFATE POWDER N/AGENTLELAX POWDER N/AGENVOYA TABLET N/AGERI-DRYL 25 MG TABLET N/AGERI-HYDROLAC 12% CREAM N/AGERI-HYDROLAC 12% LOTION N/AGERI-KOT 8.6 MG TABLET N/AGERI-PECTATE 262 MG/15 ML SUSP N/AGERI-TUSSIN 100 MG/5 ML SOLN N/AGIANVI 3 MG-0.02 MG TABLET N/AGILENYA 0.5 MG CAPSULE N/AGILTUSS TR TABLET N/AGLATIRAMER 40 MG/ML SYRINGE N/AGLATOPA 20 MG/ML SYRINGE N/AGLIMEPIRIDE 1 MG TABLET N/AGLIMEPIRIDE 2 MG TABLET N/AGLIMEPIRIDE 4 MG TABLET N/AGLIPIZIDE 10 MG TABLET N/AGLIPIZIDE 5 MG TABLET N/AGLIPIZIDE ER 10 MG TABLET N/AGLIPIZIDE ER 2.5 MG TABLET N/AGLIPIZIDE ER 5 MG TABLET N/AGLIPIZIDE POWDER N/AGLIPIZIDE XL 10 MG TABLET N/AGLIPIZIDE XL 2.5 MG TABLET N/AGLIPIZIDE XL 5 MG TABLET N/AGLIPIZIDE-METFORMIN 2.5-250 MG N/AGLIPIZIDE-METFORMIN 2.5-500 MG N/AGLIPIZIDE-METFORMIN 5-500 MG N/AGLUCAGEN 1 MG HYPOKIT N/AGLUCAGEN DIAGNOSTIC 1 MG VIAL N/AGLUCOCOM 28G LANCETS N/AGLUCOCOM 30G LANCETS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GLUCOCOM 33G LANCETS N/AGLUCOCOM AUTOLINK SYSTEM N/AGLUCOSE 4 GRAM TABLET CHEW N/AGLYBURIDE 1.25 MG TABLET N/AGLYBURIDE 2.5 MG TABLET N/AGLYBURIDE 5 MG TABLET N/AGLYBURIDE MICRO 1.5 MG TAB N/AGLYBURIDE MICRO 3 MG TABLET N/AGLYBURIDE MICRO 6 MG TABLET N/AGLYBURIDE-METFORMIN 2.5-500 MG N/AGLYBURIDE-METFORMIN 5-500 MG N/AGLYBURID-METFORMIN 1.25-250 MG N/AGLYCERIN 99.5% LIQUID N/AGLYCERIN 99.5% SKIN PROTECT LQ N/AGLYCERIN LIQUID N/AGLYCERIN SKIN PROTECTANT LIQ N/AGLYCEROL FORMAL LIQUID N/AGLYCOLAX POWDER N/AGLYCOPYRROLATE 1 MG TABLET N/AGLYCOPYRROLATE 2 MG TABLET N/AGLYCOPYRROLATE POWDER N/AGNP ACID REDUCER 20 MG TABLET N/AGNP ALL DAY ALLERGY 10 MG TAB N/AGNP ALL DAY ALLERGY-D TABLET N/AGNP ALLERGY 25 MG CAPSULE N/AGNP ALLERGY 25 MG TABLET N/AGNP ALLERGY 4 MG TABLET N/AGNP ALLERGY RELF 5 MG/5 ML SLN N/AGNP ALLERGY RELIEF 25 MG CAP N/AGNP ALLERGY-CONGES RELF ER TAB N/AGNP ANTACID 500 MG CHEW TABLET N/AGNP ANTACID ULTRA TAB CHEW N/AGNP ANTACID XTRA STR CHEW TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GNP ANTI-DIARRHEAL 2 MG CAPLET N/AGNP ANTIFUNGAL 1% TOP CREAM N/AGNP ASPIRIN 325 MG TABLET N/AGNP ASPIRIN EC 325 MG TABLET N/AGNP ASPIRIN EC 81 MG TABLET N/AGNP CAL MAG ZINC-D3 TABLET N/AGNP CALCIUM 600 MG TABLET N/AGNP CALCIUM 600 MG-D3 800 UNIT N/AGNP CALCIUM CITRATE-VIT D3 TAB N/AGNP CASTOR OIL N/AGNP CENTURY CARDIO TABLET N/AGNP CENTURY MATURE TABLET N/AGNP CENTURY TABLET N/AGNP CHILD ALLERGY 12.5 MG/5 ML N/AGNP CHLD ALL DAY ALLER 1 MG/ML N/AGNP CHLD IBUPROFEN 100 MG/5 ML N/AGNP CHLD LORATADINE 5 MG/5 ML N/AGNP CIMETIDINE 200 MG TABLET N/AGNP CLEARLAX POWDER N/AGNP CLICKFINE PEN NDL 31GX5/16 N/AGNP DIABETIC SUPPORT FORM TAB N/AGNP DIPHEDRYL 12.5 MG/5 ML ELX N/AGNP DIPHEDRYL ALLERGY CAP N/AGNP FISH OIL 1;000 MG SOFTGEL N/AGNP FISH OIL 1;200 MG SOFTGEL N/AGNP FISH OIL EC 1;000 MG SFTGL N/AGNP FOLIC ACID 400 MCG TABLET N/AGNP GAS RELIEF 80 TAB CHEW N/AGNP GLUCOSE 4 GRAM TABLET CHEW N/AGNP GLYCERIN 99.5% LIQUID N/AGNP HAIR; SKIN AND NAILS TAB N/AGNP HEALTHY EYES TABLET N/AGNP HYDROCORT ACETATE 1% CR N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GNP HYDROCORTISONE 0.5% CRM N/AGNP HYDROCORTISONE 1% CREAM N/AGNP HYDROCORTISONE 1% OINTMENT N/AGNP IBUPROFEN 200 MG CAPLET N/AGNP IBUPROFEN 200 MG TABLET N/AGNP INS SYR 0.3 ML 29GX1/2'' N/AGNP INSUL SYR 0.3 ML 31GX5/16'' N/AGNP INSUL SYR 0.5 ML 31GX5/16'' N/AGNP INSULIN SYR 1 ML 31GX5/16'' N/AGNP IRON 65 MG TABLET N/AGNP K-PEC SUSPENSION N/AGNP LICE TREATMENT SHAMPOO N/AGNP LITE COAT ASA 325 MG TAB N/AGNP LORATADINE 10 MG TABLET N/AGNP LORATADINE 5 MG/5 ML SYRUP N/AGNP MEGA MULTI FOR MEN TABLET N/AGNP MEGA MULTI FOR WOMEN TAB N/AGNP MICONAZOLE 3 COMBO PACK N/AGNP MICONAZOLE 7 CREAM N/AGNP MICRO THIN 33G LANCETS N/AGNP MOTION SICKNES 25 MG TAB N/AGNP MUCUS ER 600 MG TABLET N/AGNP NASAL SPRAY 0.05% N/AGNP NASAL SPRAY ORIGINAL 0.05% N/AGNP NATURAL FIBER LAXATIVE CAP N/AGNP NATURAL FIBER POWDER N/AGNP NIACIN 250 MG TABLET N/AGNP NO DRIP 0.05% NASAL SPRAY N/AGNP OMEPRAZOLE DR 20 MG TABLET N/AGNP ONE DAILY TABLET N/AGNP PAIN RELIEF 500 MG CAPLET N/AGNP PAIN RELIEF ER 650 MG CPLT N/AGNP PAIN RELIEVER 325 MG TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GNP PAIN RELIEVER 500 MG CAPLT N/AGNP PAIN RELIEVER 500 MG TAB N/AGNP PETROLEUM JELLY N/AGNP PINK BISMUTH 262 MG/15 ML N/AGNP PINK BISMUTH MAX-STR SUSP N/AGNP QUICK DISSOLVE GLUCOSE TAB N/AGNP SENNA-LAX 8.6 MG TABLET N/AGNP TERBINAFINE 1% CREAM N/AGNP THERAPEUTIC-M CAPLET N/AGNP TRIPLE ANTIBIOTIC OINTMENT N/AGNP TUSSIN 100 MG/5 ML SYRUP N/AGNP TUSSIN CF COUGH-COLD SYRUP N/AGNP TUSSIN DM CLEAR SYRUP N/AGNP TUSSIN DM SYRUP N/AGNP ULT C 0.3ML 29GX1/2'' (1/2) N/AGNP ULT CMFRT 0.5 ML 29GX1/2'' N/AGNP ULTR CMFRT 0.5 ML 28GX1/2'' N/AGNP ULTR CMFRT 0.5 ML 30GX5/16 N/AGNP ULTR COMFORT 1 ML 29GX1/2'' N/AGNP ULTRA COMFORT 0.5 ML SYR N/AGNP ULTRA COMFORT 1 ML SYRINGE N/AGNP ULTRA COMFORT 3/10 ML SYR N/AGNP ULTRA COMFRT 1 ML 28GX1/2'' N/AGNP UNIVERSAL 1 STANDARD 21G N/AGNP UNIVERSAL 1 SUPER THIN 30G N/AGNP UNIVERSAL 1 THIN 26G LANCT N/AGNP VIT D3 10MCG(400 UNIT) CHW N/AGNP VITAMIN B-6 100 MG TABLET N/AGNP VITAMIN D3 1;000 UNIT TAB N/AGNP VITAMIN D3 10 MCG TABLET N/AGNP VITAMIN D3 2;000 UNIT TAB N/AGNP VITAMIN D3 25 MCG TABLET N/AGNP VITAMIN D3 25MCG(1000 UNT) N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GNP VITAMIN D3 5;000 UNIT TAB N/AGNP WART REMOVER SOLUTION N/AGOJJI LANCETS 30G N/AGOLYTELY PACKET N/AGRANISETRON HCL 1 MG TABLET N/AGRAPE ARTIFICIAL FLAVOR LIQUID N/AGRAPE CONCENTRATE FLAVOR LIQ N/AGRAPE FLAVOR N/AGRAPE FLAVOR LIQUID N/AGRAPE FLAVOR SYRUP N/AGRAPEFRUIT OIL N/AGREAT VALUE DISTILLED WATER N/AGRISEOFULVIN 125 MG/5 ML SUSP N/AGRISEOFULVIN MICRO 500 MG TAB N/AGRISEOFULVIN ULTRA 125 MG TAB N/AGRISEOFULVIN ULTRA 250 MG TAB N/AGS ALL DAY ALLERGY 10 MG TAB N/AGS ALLER-EASE 180 MG TABLET N/AGS ALLERGY RELIEF 10 MG TABLET N/AGS ALLERGY RELIEF 25 MG CAP N/AGS ALLERGY RELIEF 25 MG TABLET N/AGS ALLERGY RELIEF 4 MG TABLET N/AGS ANTACID 500 MG CHEWABLE TAB N/AGS ANTI-DIARRHEAL 2 MG CAPLET N/AGS ANTI-ITCH 1% CREAM N/AGS ARTHRITIS PAIN ER 650 MG N/AGS ASPIRIN 325 MG TABLET N/AGS ASPIRIN EC 325 MG TABLET N/AGS CAL ANTACID 500 MG CHEW TAB N/AGS CHILD ALL DAY ALLER 1 MG/ML N/AGS CHILD ALLERGY 12.5 MG/5 ML N/AGS CHILD IBUPROFEN 100 MG/5 ML N/AGS CHILD MUCUS RELIEF M-S COLD N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

GS CHILD MUCUS RLF COUGH LIQ N/AGS CLEARLAX POWDER N/AGS FIRST AID ANTIBIOTIC OINT N/AGS GLUCOSE 4 GRAM TABLET CHEW N/AGS IBUPROFEN 200 MG CAPLET N/AGS IBUPROFEN 200 MG TABLET N/AGS ITCHY EYE 0.025% DROPS N/AGS LANSOPRAZOLE DR 15 MG CAP N/AGS LICE KILLING SHAMPOO N/AGS LUBRICAT PLUS 0.5% EYE DRPS N/AGS NASAL ALLERGY 24HR SPRAY N/AGS NASAL SPRAY 0.05% N/AGS OMEPRAZOLE DR 20 MG TABLET N/AGS PAIN RELIEF 325 MG TABLET N/AGS PAIN RELIEF 500 MG CAPLET N/AGS PAIN RELIEF 500 MG TABLET N/AGS SENNA LAXATIVE 8.6 MG TAB N/AGS SIMETHICONE 20 MG/0.3 ML N/AGS SINUS NASAL SPRAY 0.05% N/AGS SLEEP AID 25 MG TABLET N/AGS STOMACH RELIEF 525 MG/30 ML N/AGS TUSSIN CF LIQUID N/AGS TUSSIN DM COUGH SYRUP N/AGS TUSSIN DM COUGH-CHEST SOLN N/AGS TUSSIN DM LIQUID N/AGS TUSSIN MUCUS-CONG 100 MG/5 N/AGS TUSSIN MUCUS-CONG 200 MG/10 N/AGS UNIVERSAL 1 MICRO THIN 33G N/AGS UNIVERSAL 1 THIN 26G LANCET N/AGS UNIVERSAL 1 ULTRA THIN 30G N/AG-SUPRESS DX DROPS N/AG-TRON PED LIQUID N/AG-TRON PEDIATRIC DROPS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

G-TUSICOF LIQUID N/AGUAIASORB DM LIQUID N/AGUAIATUSSIN AC LIQUID N/AGUAICON DMS LIQUID PACKET N/AGUAIFEN-CODEINE 100-10 MG/5 ML N/AGUAIFENESIN 100 MG/5 ML LIQUID N/AGUAIFENESIN 100 MG/5 ML SOLN N/AGUAIFENESIN 100 MG/5 ML SYRUP N/AGUAIFENESIN 200 MG/10 ML SOLN N/AGUAIFENESIN 300 MG/15 ML SOLN N/AGUAIFENESIN AC COUGH SYRUP N/AGUAIFENESIN DAC ORAL SOLUTION N/AGUAIFENESIN DM SYRUP N/AGUAIFENESIN POWDER N/AGUAIFENESIN-CODEINE SYRUP N/AGUANFACINE 1 MG TABLET N/AGUANFACINE 2 MG TABLET N/AGUANFACINE HCL ER 1 MG TABLET N/AGUANFACINE HCL ER 2 MG TABLET N/AGUANFACINE HCL ER 3 MG TABLET N/AGUANFACINE HCL ER 4 MG TABLET N/AGUAVA FLAVOR LIQUID N/AGUM BASE GELATIN N/AHAIR FORMULA TABLET N/AHAIR; SKIN AND NAILS CAPLET N/AHAIR; SKIN AND NAILS SOFTGEL N/AHALOBETASOL PROP 0.05% CREAM N/AHALOBETASOL PROP 0.05% OINTMNT N/AHAVRIX 1;440 UNITS/ML SYRINGE N/AHAVRIX 1;440 UNITS/ML VIAL N/AHEALTHY ACCENTS AUTOLET DEVICE N/AHEALTHY ACCENTS PENTIP 4MM 32G N/AHEALTHY ACCENTS PENTIP 5MM 31G N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HEALTHY ACCENTS PENTIP 6MM 31G N/AHEALTHY ACCENTS PENTIP 8MM 31G N/AHEALTHY ACCENTS PENTP 12MM 29G N/AHEALTHY ACCENTS UNILET 30G N/AHEALTHY EYES TABLET N/AHEALTHYLAX POWDER PACKET N/AHEARTBURN RELIEF 20 MG TABLET N/AHEARTBURN RELIEF 200 MG TABLET N/AHEARTBURN TREATMNT 24 HR 15 MG N/AHEATHER 0.35 MG TABLET N/AHEB INCONTROL ALCOHOL 70% PADS N/AHEB MICRO THIN 33G LANCETS N/AHEB UNIFINE PNTP PLUS 31GX3/16 N/AHEMA-COMBISTIX REAGENT STRIPS N/AHEPARIN 2;000 UNIT/2 ML VIAL N/AHEPARIN 40;000 UNIT/4 ML VIAL N/AHEPARIN 50;000 UNIT/10 ML VIAL N/AHEPARIN 50;000 UNIT/5 ML VIAL N/AHEPARIN SOD 10;000 UNIT/ML VL N/AHEPARIN SOD 20;000 UNIT/ML VL N/AHEPARIN SOD 5;000 UNIT/ML VIAL N/AHEPSERA 10 MG TABLET N/AHM ADT TUSSIN COUGH CONG DM LQ N/AHM ADT TUSSIN M-S COLD LIQUID N/AHM ADULT TUSSIN CHEST CONG LIQ N/AHM ADULT TUSSIN DM SYRUP N/AHM ALCOHOL 70% PREP PADS N/AHM ALL DAY ALLERGY 10 MG TAB N/AHM ALLERGY 25 MG CAPSULE N/AHM ALLERGY 25 MG TABLET N/AHM ALLERGY COMPLETE-D TABLET N/AHM ALLERGY RELIEF 10 MG TABLET N/AHM ALLERGY RELIEF 25 MG CAP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HM ALLERGY RELIEF 25 MG TABLET N/AHM ALLERGY RELIEF 4 MG TABLET N/AHM ALLERGY RELIEF 50 MCG SPRAY N/AHM ALLERGY RLF-NASAL DECONG TB N/AHM ALLERGY-CONGESTION 12HR TAB N/AHM ANTI-DIARRHEAL 2 MG CAPLET N/AHM ANTIOXIDANT VITAMINS TABLET N/AHM ARTHRIT PAIN RLF ER 650 MG N/AHM ARTHRITIS PAIN ER 650 MG N/AHM ASPIRIN 325 MG TABLET N/AHM ASPIRIN EC 325 MG TABLET N/AHM ASPIRIN EC 81 MG TABLET N/AHM CAL ANTACID 1000 MG CHEW TB N/AHM CAL ANTACID 500 MG CHEW TAB N/AHM CAL ANTACID 750 MG CHEW TAB N/AHM CAL CIT 315 MG-D3 250 UNIT N/AHM CALCIUM 600-D3-MINERALS TAB N/AHM CALCIUM 600-VIT D3 400 TAB N/AHM CALCIUM 600-VIT D3 800 TAB N/AHM CALCIUM CITRATE-VIT D3 TAB N/AHM CASTOR OIL N/AHM CHILD ALL DAY ALLER 1 MG/ML N/AHM CHILD ALLERGY 12.5 MG/5 ML N/AHM CHILD CETIRIZINE 1 MG/ML N/AHM CHILD IBUPROFEN 100 MG/5 ML N/AHM CHILD LORATADINE 5 MG/5 ML N/AHM CLEARLAX POWDER N/AHM COMPLETE 50 PLUS TABLET N/AHM COMPLETE MEN 50 PLUS TABLET N/AHM COMPLETE MULTI-VIT-MINERAL N/AHM EYE ITCH RELIEF 0.025% DROP N/AHM FAMOTIDINE 20 MG TABLET N/AHM FEXOFENADINE HCL 180 MG TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HM FEXOFENADINE HCL 60 MG TAB N/AHM FIBER 0.52 GRAM CAPSULE N/AHM FIBER POWDER N/AHM FISH OIL 1;200 MG SOFTGEL N/AHM FISH OIL 554 MG SOFTGEL N/AHM FISH OIL EC 1;000 MG SFTGL N/AHM FOLIC ACID 400 MCG TABLET N/AHM GAS RELIEF 80 MG TAB CHEW N/AHM GLYCERIN 99.5% LIQUID N/AHM HYDROCORTISONE 1% CREAM N/AHM IBUPROFEN 200 MG CAPLET N/AHM IBUPROFEN 200 MG TABLET N/AHM IBUPROFEN IB 200 MG CAPLET N/AHM IBUPROFEN IB 200 MG TABLET N/AHM INF GAS RELIEF 20 MG/0.3 ML N/AHM IRON 65 MG TABLET N/AHM LANSOPRAZOLE DR 15 MG CAP N/AHM LICE KILLING SHAMPOO N/AHM LICE TREATMENT 1% CRM RINSE N/AHM LOPERAMIDE 2 MG SOFTGEL N/AHM LORATADINE 10 MG TABLET N/AHM LUBRICAT PLUS 0.5% EYE DRPS N/AHM MEN'S ONE DAILY TABLET N/AHM MOTION RELIEF 25 MG TABLET N/AHM MUCUS ER 600 MG TABLET N/AHM NIACIN TR 250 MG TABLET N/AHM OMEPRAZOLE DR 20 MG TABLET N/AHM ONE DAILY WOMEN'S 50 PLUS N/AHM ORIGINAL NASAL SPRAY 0.05% N/AHM PAIN RELIEF 500 MG CAPLET N/AHM PAIN RELIEF 500 MG TABLET N/AHM PAIN RELIEVER 325 MG TABLET N/AHM PAIN RELIEVER 500 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HM PETROLEUM JELLY N/AHM SENNA 8.6 MG TABLET N/AHM SINUS NASAL SPRAY 0.05% N/AHM SLEEP AID 25 MG TABLET N/AHM STOMACH RELIEF 262 MG/15 ML N/AHM STOMACH RELIEF 525 MG/15 ML N/AHM STOMACH RELIEF 525 MG/30 ML N/AHM STOOL SOFTENER 100 MG SFTGL N/AHM STOOL SOFTENER 100 MG TAB N/AHM TRIPLE ANTIBIOTIC OINTMENT N/AHM ULTIMATE WOMEN'S 50+ TABLET N/AHM VITAMIN B-6 100 MG TABLET N/AHM VITAMIN D3 1;000 UNIT TAB N/AHM VITAMIN D3 2;000 UNIT SFTGL N/AHM WOMEN'S ONE DAILY TABLET N/AHOMATROPAIRE 5% EYE DROPS N/AHONEY FLAVOR LIQUID N/AHUMULIN 70-30 VIAL N/AHUMULIN N 100 UNIT/ML VIAL N/AHUMULIN R 100 UNIT/ML VIAL N/AHUMULIN R 500 UNIT/ML VIAL N/AHV TUSSIN MUCUS-CONG 200 MG/10 N/AHYALGAN 20 MG/2 ML SYRINGE N/AHYALGAN 20 MG/2 ML VIAL N/AHYDRALAZINE 10 MG TABLET N/AHYDRALAZINE 100 MG TABLET N/AHYDRALAZINE 25 MG TABLET N/AHYDRALAZINE 50 MG TABLET N/AHYDROCERIN CREAM N/AHYDROCHLOROTHIAZIDE 12.5 MG CP N/AHYDROCHLOROTHIAZIDE 12.5 MG TB N/AHYDROCHLOROTHIAZIDE 25 MG TAB N/AHYDROCHLOROTHIAZIDE 50 MG TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HYDROCHLOROTHIAZIDE POWDER N/AHYDROCODONE BITARTRATE POWDER N/AHYDROCODONE-ACETAMIN 10-300 MG N/AHYDROCODONE-ACETAMIN 10-325 MG N/AHYDROCODONE-ACETAMIN 2.5-325 N/AHYDROCODONE-ACETAMIN 5-300 MG N/AHYDROCODONE-ACETAMIN 5-325 MG N/AHYDROCODONE-ACETAMIN 7.5-300 N/AHYDROCODONE-ACETAMIN 7.5-325 N/AHYDROCODONE-ACETAMN 7.5-325/15 N/AHYDROCODONE-HOMATROPINE 5-1.5 N/AHYDROCODONE-HOMATROPINE SOLN N/AHYDROCODONE-HOMATROPINE SYRUP N/AHYDROCODONE-IBUPROFEN 10-200 N/AHYDROCODONE-IBUPROFEN 5-200 MG N/AHYDROCODONE-IBUPROFEN 7.5-200 N/AHYDROCORTISON-ACETIC ACID SOLN N/AHYDROCORTISONE 0.5% CREAM N/AHYDROCORTISONE 0.5% OINTMENT N/AHYDROCORTISONE 1% LOTION N/AHYDROCORTISONE 10 MG TABLET N/AHYDROCORTISONE 100 MG/60 ML N/AHYDROCORTISONE 2.5% CREAM N/AHYDROCORTISONE 2.5% LOTION N/AHYDROCORTISONE 2.5% OINTMENT N/AHYDROCORTISONE 20 MG TABLET N/AHYDROCORTISONE 5 MG TABLET N/AHYDROCORTISONE ACETATE POWDER N/AHYDROCORTISONE BUTY 0.1% CREAM N/AHYDROCORTISONE BUTYR 0.1% OINT N/AHYDROCORTISONE BUTYR 0.1% SOLN N/AHYDROCORTISONE MICRONIZED PWD N/AHYDROCORTISONE PLUS 1% CREAM N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HYDROCORTISONE POWDER N/AHYDROCORTISONE VAL 0.2% CREAM N/AHYDROCORTISONE VAL 0.2% OINTMT N/AHYDROCORTISONE-ALOE 1% CREAM N/AHYDROCORT-PRAMOXINE 1%-1% CRM N/AHYDROMET SYRUP N/AHYDROMORPHONE 2 MG TABLET N/AHYDROMORPHONE 4 MG TABLET N/AHYDROMORPHONE 8 MG TABLET N/AHYDROMORPHONE HCL POWDER N/AHYDROXYCHLOROQUINE 200 MG TAB N/AHYDROXYPROGEST 1;250 MG/5 ML N/AHYDROXYPROGEST 250 MG/ML VIAL N/AHYDROXYPROGESTERONE 1.25 G/5ML N/AHYDROXYPROGESTERONE CAP POWDER N/AHYDROXYUREA 500 MG CAPSULE N/AHYDROXYZINE 50 MG/25 ML SYRUP N/AHYDROXYZINE HCL 10 MG TABLET N/AHYDROXYZINE HCL 25 MG TABLET N/AHYDROXYZINE HCL 50 MG TABLET N/AHYDROXYZINE PAM 100 MG CAP N/AHYDROXYZINE PAM 25 MG CAP N/AHYDROXYZINE PAM 50 MG CAP N/AHYDROXYZINE PAMOATE POWDER N/AHYOSCYAMINE 0.125 MG ODT N/AHYOSCYAMINE 0.125 MG TAB SL N/AHYOSCYAMINE 0.125 MG/5 ML ELIX N/AHYOSCYAMINE 0.125 MG/ML DROP N/AHYOSCYAMINE ER 0.375 MG TAB N/AHYOSCYAMINE SR 0.375 MG TAB N/AHYOSCYAMINE SULF 0.125 MG TAB N/AHYOSCYAMINE SULFATE POWDER N/AHYOSYNE 0.125 MG/ML DROP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

HYOSYNE 125 MCG/5 ML ELIXIR N/AHYPERRHO S-D 1;500 UNIT SYRING N/AHYPERRHO S-D 250 UNIT SYRINGE N/AHYPOLANCE AST LANCING KIT N/AIBU 400 MG TABLET N/AIBU 600 MG TABLET N/AIBU 800 MG TABLET N/AIBU-200 200 MG TABLET N/AIBUDONE 10-200 MG TABLET N/AIBUPROFEN 100 MG/5 ML SUSP N/AIBUPROFEN 200 MG CAPLET N/AIBUPROFEN 200 MG TABLET N/AIBUPROFEN 400 MG TABLET N/AIBUPROFEN 600 MG TABLET N/AIBUPROFEN 800 MG TABLET N/AIBUPROFEN POWDER N/AICAPS AREDS FORMULA DR TABLET N/AICAPS MV TABLET N/AICLUSIG 15 MG TABLET N/AIMIQUIMOD 5% CREAM PACKET N/AINCONTROL LANCING DEVICE N/AINCONTROL PEN NEEDLE 12MM 29G N/AINCONTROL PEN NEEDLE 4MM 32G N/AINCONTROL PEN NEEDLE 5MM 31G N/AINCONTROL PEN NEEDLE 6MM 31G N/AINCONTROL PEN NEEDLE 8MM 31G N/AINCONTROL SUPER THIN 30G LANCT N/AINCONTROL ULTRA THIN 28G LANCT N/AINCRELEX 40 MG/4 ML VIAL N/AINCRUSE ELLIPTA 62.5 MCG INH N/AINDAPAMIDE 1.25 MG TABLET N/AINDAPAMIDE 2.5 MG TABLET N/AINDOMETHACIN 1 MG VIAL N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

INDOMETHACIN 25 MG CAPSULE N/AINDOMETHACIN 50 MG CAPSULE N/AINDOMETHACIN ER 75 MG CAPSULE N/AINDOMETHACIN POWDER N/AINF GAS REL 20 MG/0.3 ML DROP N/AINFANT GAS RELIEF DROPS N/AINFANT GAS RLF 20 MG/0.3 ML N/AINFANTS' GAS RLF 20 MG/0.3 ML N/AINJECT EASE 28G LANCETS N/AINJECT EASE 30G LANCETS N/AINJECT-EASE SYR NDL INTRODUCER N/AINSPIRACHAMBER N/AINSPIRACHAMBER WITH MASK-LARGE N/AINSPIRACHAMBER WITH MASK-MED N/AINSPIRACHAMBER WITH MASK-SMALL N/AINSULIN 1 ML SYRINGE N/AINSULIN 1/2 ML SYRINGE N/AINSULIN 3/10 ML SYRINGE N/AINSULIN LISPRO 100 UNIT/ML PEN N/AINSULIN LISPRO 100 UNIT/ML VL N/AINSULIN LISPRO JR 100 UNIT/ML N/AINSULIN LISPRO MIX 75-25 KWKPN N/AINSULIN SYR 0.3 ML 30GX5/16'' N/AINSULIN SYRIN 0.3 ML 29GX1/2'' N/AINSULIN SYRIN 0.3 ML 30GX1/2'' N/AINSULIN SYRIN 0.3 ML 30GX5/16'' N/AINSULIN SYRIN 0.3 ML 31GX5/16'' N/AINSULIN SYRIN 0.5 ML 28GX1/2'' N/AINSULIN SYRIN 0.5 ML 29GX1/2'' N/AINSULIN SYRIN 0.5 ML 30GX1/2'' N/AINSULIN SYRIN 0.5 ML 30GX5/16'' N/AINSULIN SYRIN 0.5 ML 31GX5/16'' N/AINSULIN SYRIN 1 ML 29GX1/2'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

INSULIN SYRING 0.5 ML 29GX1/2'' N/AINSULIN SYRINGE 0.3 ML N/AINSULIN SYRINGE 1 ML N/AINSULIN SYRINGE 1 ML 28GX1/2'' N/AINSULIN SYRINGE 1 ML 29GX1/2'' N/AINSULIN SYRINGE 1 ML 30GX1/2'' N/AINSULIN SYRINGE 1 ML 30GX5/16'' N/AINSULIN SYRINGE 1 ML 31GX5/16'' N/AINSUPEN PEN NEEDLE 29GX12MM N/AINSUPEN PEN NEEDLE 30GX8MM N/AINSUPEN PEN NEEDLE 31GX5/16'' N/AINSUPEN PEN NEEDLE 31GX6MM N/AINSUPEN PEN NEEDLE 31GX8MM N/AINSUPEN PEN NEEDLE 32GX4MM N/AINSUPEN PEN NEEDLE 32GX6MM N/AINSUPEN PEN NEEDLE 32GX8MM N/AINSUPEN PEN NEEDLE 33GX4MM N/AINTELENCE 100 MG TABLET N/AINTELENCE 200 MG TABLET N/AINTELENCE 25 MG TABLET N/AINTRON A 10 MILLION UNITS VIAL N/AINTRON A 18 MILLION UNIT/3 ML N/AINTRON A 18 MILLION UNITS VIAL N/AINTRON A 25 MILLION UNIT/2.5ML N/AINTRON A 50 MILLION UNITS VIAL N/AINTROVALE 0.15-0.03 MG TABLET N/AINVACARE 30G LANCETS N/AINVACARE LANCING DEVICE N/AINVIRASE 500 MG TABLET N/AINZO ANTIFUNGAL 2% CREAM N/AIODOQUINOL POWDER N/AIONIL T SHAMPOO N/AIPECAC SYRUP N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

IPRAT-ALBUT 0.5-3(2.5) MG/3 ML N/AIPRATROPIUM 0.03% SPRAY N/AIPRATROPIUM 0.06% SPRAY N/AIPRATROPIUM BR 0.02% SOLN N/AIPRATROPIUM BROMIDE POWDER N/AI-PRIN 200 MG TABLET N/AIRBESARTAN 150 MG TABLET N/AIRBESARTAN 300 MG TABLET N/AIRBESARTAN 75 MG TABLET N/AIRON 65 MG TABLET N/AISENTRESS 100 MG POWDER PACKET N/AISENTRESS 100 MG TABLET CHEW N/AISENTRESS 25 MG TABLET CHEW N/AISENTRESS 400 MG TABLET N/AISENTRESS HD 600 MG TABLET N/AISONIAZID 100 MG TABLET N/AISONIAZID 300 MG TABLET N/AISONIAZID 50 MG/5 ML SOLUTION N/AISONIAZID POWDER N/AISOSORBIDE DINITR ER 40 MG TAB N/AISOSORBIDE DINITRATE 10 MG TAB N/AISOSORBIDE DINITRATE 20 MG TAB N/AISOSORBIDE DINITRATE 30 MG TAB N/AISOSORBIDE DINITRATE 5 MG TAB N/AISOSORBIDE MONONIT 10 MG TAB N/AISOSORBIDE MONONIT 20 MG TAB N/AISOSORBIDE MONONIT ER 120 MG N/AISOSORBIDE MONONIT ER 30 MG TB N/AISOSORBIDE MONONIT ER 60 MG TB N/AISRADIPINE 2.5 MG CAPSULE N/AISRADIPINE 5 MG CAPSULE N/AITRACONAZOLE 10 MG/ML SOLUTION N/AITRACONAZOLE 100 MG CAPSULE N/A

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IVERMECTIN 3 MG TABLET N/AI-VITE PROTECT TABLET N/AI-VITE TABLET N/AJANTOVEN 1 MG TABLET N/AJANTOVEN 10 MG TABLET N/AJANTOVEN 2 MG TABLET N/AJANTOVEN 2.5 MG TABLET N/AJANTOVEN 3 MG TABLET N/AJANTOVEN 4 MG TABLET N/AJANTOVEN 5 MG TABLET N/AJANTOVEN 6 MG TABLET N/AJANTOVEN 7.5 MG TABLET N/AJENCYCLA 0.35 MG TABLET N/AJIVI 1;000 UNIT VIAL N/AJIVI 2;000 UNIT VIAL N/AJIVI 3;000 UNIT VIAL N/AJIVI 500 UNIT VIAL N/AJOCK ITCH 1% CREAM N/AJOCK ITCH RELIEF 1% CREAM N/AJOLESSA 0.15 MG-0.03 MG TABLET N/AJR PAIN-FEVER 160 MG RAPID TAB N/AJULEBER 28 DAY TABLET N/AJULUCA 50-25 MG TABLET N/AJUNEL 1 MG-20 MCG TABLET N/AJUNEL 1.5 MG-30 MCG TABLET N/AJUNEL FE 1 MG-20 MCG TABLET N/AJUNEL FE 1.5 MG-30 MCG TABLET N/AJUNEL FE 24 TABLET N/AJUNIOR PAIN RELIEVER 160 MG N/AKAHLUA FLAVOR LIQUID N/AKAITLIB FE CHEWABLE TABLET N/AKALETRA 100-25 MG TABLET N/AKALETRA 200-50 MG TABLET N/A

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KALETRA 80 MG-20 MG/ML SOLN N/AKAOPECTATE 262 MG/15 ML SUSP N/AKAOPECTATE EXTRA STRENGTH LIQ N/AKARIVA 28 DAY TABLET N/AKELNOR 1-35 28 TABLET N/AKETOCONAZOLE 2% CREAM N/AKETOCONAZOLE 2% SHAMPOO N/AKETOCONAZOLE 200 MG TABLET N/AKETO-DIASTIX REAGENT STRIPS N/AKETOPROFEN 50 MG CAPSULE N/AKETOPROFEN 75 MG CAPSULE N/AKETOPROFEN ER 200 MG CAPSULE N/AKETOROLAC 0.4% OPHTH SOLUTION N/AKETOROLAC 0.5% OPHTH SOLUTION N/AKETOROLAC 10 MG TABLET N/AKETOSTIX REAGENT STRIP N/AKETOTIFEN FUM 0.025% EYE DROPS N/AKIMONO CONDOMS N/AKIMONO MAXX CONDOM N/AKIMONO MICROTHIN AQUA LUBE N/AKIMONO MICROTHIN CONDOM N/AKIMONO MICROTHIN LARGE CONDOM N/AKIMONO TEXTURED CONDOM N/AKINRAY INS SYR 1 ML 31GX5/16'' N/AKINRAY SYRING 0.3 ML 31GX5/16'' N/AKINRAY SYRING 0.5 ML 31GX5/16'' N/AKIONEX 15 GM/60 ML SUSPENSION N/AKLOR-CON 10 MEQ TABLET N/AKLOR-CON 20 MEQ PACKET N/AKLOR-CON 8 MEQ TABLET N/AKLOR-CON M10 TABLET N/AKLOR-CON M15 TABLET N/AKLOR-CON M20 TABLET N/A

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KLOR-CON-EF 25 MEQ TAB EFF N/AKMART VALU PLUS SYR 1/2 ML N/AKONSYL 6 GM PACKET N/AKONSYL FORMULA-D FIBER POWDER N/AKONSYL PSYLLIUM FIBER PACKET N/AKONSYL PSYLLIUM FIBER POWDER N/AK-PAX IMMUNE SUPPORT TABLET N/AK-PEC SUSPENSION N/AK-PHOS #2 TABLET N/AK-PHOS ORIGINAL TABLET N/AKPN PRENATAL TABLET N/AKRO ACETAMINOPHEN 325 MG TAB N/AKRO ALL DAY ALLERGY 10 MG TAB N/AKRO ALLERGY 25 MG TABLET N/AKRO ASPIRIN 325 MG TABLET N/AKRO AUTOLET LANCING DEVICE N/AKRO CHILD MUCUS RLF COUGH LIQ N/AKRO CHLD IBUPROFEN 100 MG/5 ML N/AKRO GENTLELAX 17 GRAM POWDER N/AKRO GLUCOSE 4 GRAM TABLET CHEW N/AKRO IBUPROFEN 200 MG CAPLET N/AKRO IBUPROFEN 200 MG TABLET N/AKRO INS SYR 0.3 ML 29GX1/2'' N/AKRO INS SYRIN 0.5 ML 31GX5/16'' N/AKRO INSULIN SYR 1 ML 30GX5/16'' N/AKRO LANCING DEVICE N/AKRO MICONAZOLE 7 CREAM N/AKRO NASAL SPRAY ORIGINAL 0.05% N/AKRO PEN NEEDLE 6MM X 31G N/AKRO PEN NEEDLE 8MM X 31G N/AKRO STOMACH RLF 262 MG/15 ML N/AKRO TUSSIN DM LIQUID N/AKRO UNIVERSAL 1 THIN 26G LANCT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

KROGER GLUCOSE 4 GRAM TAB CHEW N/AKROGER INS SYR 0.3 ML 30GX5/16 N/AKROGER INS SYR 0.5 ML 29GX1/2'' N/AKROGER INS SYR 1 ML 29GX1/2'' N/AKROGER INS SYR 1 ML 31GX5/16'' N/AKROGER LANCETS N/AKROGER LANCING DEVICE N/AKROGER SUPER THIN LANCETS N/AKROGER SYR 0.5 ML 30GX5/16'' N/AKROGER SYRING 0.3 ML 31GX5/16'' N/AKURVELO-28 TABLET N/AKYLEENA 19.5 MG SYSTEM N/ALABETALOL HCL 100 MG TABLET N/ALABETALOL HCL 200 MG TABLET N/ALABETALOL HCL 300 MG TABLET N/ALABSTIX REAGENT STRIPS N/ALACTOSE ANHYDROUS POWDER N/ALACTOSE MONOHYDRATE POWDER N/ALACTOSE POWDER N/ALACTULOSE 10 GM/15 ML SOLUTION N/ALACTULOSE 20 GM/30 ML SOLUTION N/ALAMIVUDINE 10 MG/ML ORAL SOLN N/ALAMIVUDINE 150 MG TABLET N/ALAMIVUDINE 300 MG TABLET N/ALAMIVUDINE HBV 100 MG TABLET N/ALAMIVUDINE-ZIDOVUDINE TABLET N/ALANCETS N/ALANCETS 26G X 1.8MM N/ALANCETS 28G LANCETS N/ALANCETS 30G N/ALANCETS 33G N/ALANCETS THIN 23G N/ALANCETS ULTRA FINE 28G N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

LANCETS ULTRA THIN 26G N/ALANCING DEVICE N/ALANSOPRAZOLE DR 15 MG CAPSULE N/ALANSOPRAZOLE DR 30 MG CAPSULE N/ALANSOPRAZOLE ODT 15 MG TABLET N/ALANSOPRAZOLE ODT 30 MG TABLET N/ALANZO LANCING DEVICE N/ALARIN 1.5 MG-30 MCG TABLET N/ALARIN 21 1-20 TABLET N/ALARIN 24 FE 1 MG-20 MCG TABLET N/ALARIN FE 1.5-30 TABLET N/ALARIN FE 1-20 TABLET N/ALATANOPROST 0.005% EYE DROPS N/ALAYOLIS FE CHEWABLE TABLET N/AL-CARNITINE 250 MG CAPSULE N/AL-CARNITINE 500 MG CAPSULE N/AL-CARNITINE 500 MG TABLET N/ALEADER GLUCOSE 4 GM TAB CHEW N/ALEADER INS SYR 0.3 ML 29GX1/2'' N/ALEADER INS SYR 0.5 ML 28GX1/2'' N/ALEADER INS SYR 0.5 ML 29GX1/2'' N/ALEADER INS SYR 0.5 ML 30GX1/2'' N/ALEADER INS SYR 1 ML 28GX1/2'' N/ALEADER INS SYR 1 ML 29GX1/2'' N/ALEADER INS SYR 1 ML 30GX5/16'' N/ALEADER INS SYR 1 ML 31GX5/16'' N/ALEADER INSULIN SYRINGE 0.3 ML N/ALEADER PEN NEEDLES 12MM 29G N/ALEADER QUICK DISSOLVE GLUC TAB N/ALEADER SYRING 0.3 ML 31GX5/16'' N/ALEADER SYRING 0.5 ML 31GX5/16'' N/ALEENA 28 TABLET N/ALEFLUNOMIDE 10 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

LEFLUNOMIDE 20 MG TABLET N/ALEMON FLAVOR N/ALEMON FLAVOR EXTRACT N/ALEMON FLAVOR EXTRACT LIQUID N/ALEMON FLAVOR OIL N/ALEMON OIL N/ALEMONADE FLAVOR OIL N/ALESSINA-28 TABLET N/ALETAIRIS 10 MG TABLET N/ALETAIRIS 5 MG TABLET N/ALETROZOLE 2.5 MG TABLET N/ALEUCOVORIN CALCIUM POWDER N/ALEUKINE 250 MCG VIAL N/ALEUPROLIDE 2WK 1 MG/0.2 ML KIT N/ALEUPROLIDE 2WK 14 MG/2.8 ML KT N/ALEVALBUTEROL TAR HFA 45MCG INH N/ALEVOBUNOLOL 0.5% EYE DROPS N/ALEVOFLOXACIN 0.5% EYE DROPS N/ALEVOFLOXACIN 250 MG TABLET N/ALEVOFLOXACIN 500 MG TABLET N/ALEVOFLOXACIN 750 MG TABLET N/ALEVONEST-28 TABLET N/ALEVONOR-E ESTRAD 0.1-0.02-0.01 N/ALEVONOR-ETH ESTRAD 0.1-0.02 MG N/ALEVONOR-ETH ESTRAD 0.15-0.03 N/ALEVONORGESTREL 1.5 MG TABLET N/ALEVORA-28 TABLET N/ALEVOTHYROXINE 100 MCG TABLET N/ALEVOTHYROXINE 112 MCG TABLET N/ALEVOTHYROXINE 125 MCG TABLET N/ALEVOTHYROXINE 137 MCG TABLET N/ALEVOTHYROXINE 150 MCG TABLET N/ALEVOTHYROXINE 175 MCG TABLET N/A

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LEVOTHYROXINE 200 MCG TABLET N/ALEVOTHYROXINE 25 MCG TABLET N/ALEVOTHYROXINE 300 MCG TABLET N/ALEVOTHYROXINE 50 MCG TABLET N/ALEVOTHYROXINE 75 MCG TABLET N/ALEVOTHYROXINE 88 MCG TABLET N/ALEVOXYL 100 MCG TABLET N/ALEVOXYL 112 MCG TABLET N/ALEVOXYL 125 MCG TABLET N/ALEVOXYL 137 MCG TABLET N/ALEVOXYL 150 MCG TABLET N/ALEVOXYL 175 MCG TABLET N/ALEVOXYL 200 MCG TABLET N/ALEVOXYL 25 MCG TABLET N/ALEVOXYL 50 MCG TABLET N/ALEVOXYL 75 MCG TABLET N/ALEVOXYL 88 MCG TABLET N/ALEXIVA 50 MG/ML SUSPENSION N/ALEXIVA 700 MG TABLET N/AL-GLUTAMINE 500 MG TABLET N/ALICE KILLING SHAMPOO N/ALICE TREATMENT 1% CREME RINSE N/ALICE TREATMENT SHAMPOO N/ALICORICE FLAVOR LIQUID N/ALIDOCAINE 5% OINTMENT N/ALIDOCAINE 5% PATCH N/ALIDOCAINE HCL 2% JELLY N/ALIDOCAINE HCL POWDER N/ALIDOCAINE-HC 2.8-0.55% GEL N/ALIDOCAINE-HC 3-0.5% CREAM N/ALIDOCAINE-HC 3-0.5% CREAM KIT N/ALIDOCAINE-HC 3-1% CREAM KIT N/ALIDOCAINE-HC 3-2.5% GEL KIT N/A

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LIDOCAINE-PRILOCAINE CREAM N/ALIDOPIN 3% CREAM N/ALILETTA 52 MG SYSTEM N/ALIME FLAVOR OIL N/ALIMONENE FLAVOR LIQUID N/ALIOTHYRONINE SOD 25 MCG TAB N/ALIOTHYRONINE SOD 5 MCG TAB N/ALIOTHYRONINE SOD 50 MCG TAB N/ALIOTHYRONINE SODIUM POWDER N/ALIQUID CALCIUM WITH VITAMIN D N/ALIQUID CORN-CALLUS REMOVER N/ALIQUID WART REMOVER 17% LIQUID N/ALISINOPRIL 10 MG TABLET N/ALISINOPRIL 2.5 MG TABLET N/ALISINOPRIL 20 MG TABLET N/ALISINOPRIL 30 MG TABLET N/ALISINOPRIL 40 MG TABLET N/ALISINOPRIL 5 MG TABLET N/ALISINOPRIL-HCTZ 10-12.5 MG TAB N/ALISINOPRIL-HCTZ 20-12.5 MG TAB N/ALISINOPRIL-HCTZ 20-25 MG TAB N/ALITE COAT ASPIRIN 325 MG TAB N/ALITE TOUCH 28G LANCETS N/ALITE TOUCH 30G LANCETS N/ALITE TOUCH 33G LANCETS N/ALITE TOUCH INSULIN 0.5 ML SYR N/ALITE TOUCH INSULIN 1 ML SYR N/ALITE TOUCH INSULIN SYR 0.3 ML N/ALITE TOUCH INSULIN SYR 0.5 ML N/ALITE TOUCH INSULIN SYR 1 ML N/ALITE TOUCH LANCING PEN N/ALITEAIRE MDI CHAMBER N/ALITETOUCH INS 0.3 ML 29GX1/2'' N/A

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LITETOUCH INS 0.3 ML 30GX5/16'' N/ALITETOUCH INS 0.3 ML 31GX5/16'' N/ALITETOUCH INS 0.5 ML 31GX5/16'' N/ALITTLE ANIMALS-IRON TAB CHEW N/ALITTLE REMEDIES FEVER 160 MG/5 N/ALIVE BETTER ADVANCED LANCING N/ALIVE BETTER PEN NEEDLES 8MM N/ALIVE BETTER ULTRA THIN LANCET N/ALO LOESTRIN FE 1-10 TABLET N/ALOHIST-D LIQUID N/ALOKELMA 10 GRAM POWDER PACKET N/ALOKELMA 5 GRAM POWDER PACKET N/ALONG ACTING 0.05% NASAL SPRAY N/ALONGS GLUCOSE 4 GRAM TAB CHEW N/ALONGS THIN LANCETS 26G N/ALONGS THIN LANCETS 30G N/ALOPERAMIDE 2 MG CAPSULE N/ALOPERAMIDE HCL POWDER N/ALOPINAVIR-RITONAVIR 80-20MG/ML N/ALORADAMED 10 MG TABLET N/ALORATADINE 10 MG ODT N/ALORATADINE 10 MG TABLET N/ALORATADINE 5 MG/5 ML SYRUP N/ALORATADINE ALLERGY 5 MG/5 ML N/ALORATADINE-D 12 HOUR TABLET N/ALORATADINE-D 24HR TABLET N/ALORCET 5-325 MG TABLET N/ALORCET HD 10-325 MG TABLET N/ALORCET PLUS 7.5-325 MG TABLET N/ALORYNA 3 MG-0.02 MG TABLET N/ALOSARTAN POTASSIUM 100 MG TAB N/ALOSARTAN POTASSIUM 25 MG TAB N/ALOSARTAN POTASSIUM 50 MG TAB N/A

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LOSARTAN-HCTZ 100-12.5 MG TAB N/ALOSARTAN-HCTZ 100-25 MG TAB N/ALOSARTAN-HCTZ 50-12.5 MG TAB N/ALOVASTATIN 10 MG TABLET N/ALOVASTATIN 20 MG TABLET N/ALOVASTATIN 40 MG TABLET N/ALOW DOSE ASPIRIN EC 81 MG TAB N/ALOW-OGESTREL-28 TABLET N/ALOZIBASE LOZENGE BASE N/ALUBRICANT 0.5% EYE DROP N/ALUBRICANT 0.5% EYE DROPS N/ALUBRICATING PLUS 0.5% EYE DRPS N/ALUDENT FLUORIDE 0.25 MG TB CHW N/ALUDENT FLUORIDE 0.5 MG TB CHEW N/ALUDENT FLUORIDE 1 MG TAB CHEW N/ALUPRON DEPOT 11.25 MG 3MO KIT N/ALUPRON DEPOT 22.5 MG 3MO KIT N/ALUPRON DEPOT 3.75 MG KIT N/ALUPRON DEPOT 45 MG 6MO KIT N/ALUPRON DEPOT 7.5 MG KIT N/ALUPRON DEPOT-4 MONTH KIT N/ALUPRON DEPOT-PED 11.25 MG 3MO N/ALUPRON DEPOT-PED 11.25 MG KIT N/ALUPRON DEPOT-PED 15 MG KIT N/ALUPRON DEPOT-PED 30 MG 3MO KIT N/ALUPRON DEPOT-PED 7.5 MG KIT N/ALUTERA-28 TABLET N/ALYZA 0.35 MG TABLET N/AMACRODANTIN 25 MG CAPSULE N/AMACUVITE EYE CARE TABLET N/AMACUVITE WITH LUTEIN TABLET N/AMAGELLAN INSUL SYRINGE 0.3 ML N/AMAGELLAN INSUL SYRINGE 0.5 ML N/A

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MAGELLAN INSULIN SYR 0.3 ML N/AMAGELLAN INSULIN SYR 0.5 ML N/AMAGELLAN INSULIN SYRINGE 1 ML N/AMAGNASWEET 110 LIQUID N/AMAGNASWEET 135 POWDER N/AMAKENA 1;250 MG/5 ML VIAL N/AMAKENA 250 MG/ML VIAL N/AMAKENA 275 MG/1.1 ML AUTOINJCT N/AMALATHION 0.5% LOTION N/AMANGO FLAVOR LIQUID N/AMANGO FLAVOR POWDER N/AMAPAP 500 MG CAPLET N/AMAPAP 500 MG CAPSULE N/AMAPAP 500 MG/15 ML LIQUID N/AMAPAP ARTHRITIS ER 650 MG CPLT N/AMAPLE FLAVOR LIQUID N/AMARLISSA-28 TABLET N/AMARSHMALLOW FLAVOR LIQUID N/AMARSHMALLOW OIL FLAVOR N/AMAVYRET 100-40 MG TABLET N/AMAXI-COMFORT INS 0.5 ML 28G N/AMAXI-COMFORT INS 1 ML 28GX1/2'' N/AMAXIMUM D3 325 MCG(13;000 UNIT N/AMEBENDAZOLE POWDER N/AMECLIZINE 12.5 MG CAPLET N/AMECLIZINE 12.5 MG TABLET N/AMECLIZINE 25 MG TABLET N/AMECLIZINE 25 MG TABLET CHEW N/AMECLIZINE HCL POWDER N/AMECLOFENAMATE 100 MG CAPSULE N/AMECLOFENAMATE 50 MG CAPSULE N/AMECLOFENAMATE SODIUM POWDER N/AMEDI-FIRST TRIPLE ANTIBIOTIC N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

MEDI-MECLIZINE 25 MG TABLET N/AMEDISENSE THIN 28G LANCETS N/AMEDISENSE THIN LANCETS N/AMEDLANCE PLUS 21G LANCETS N/AMEDLANCE PLUS 30G LANCETS N/AMEDLANCE PLUS EXTRA 21G LANCET N/AMEDLANCE PLUS LITE 25G LANCETS N/AMEDLANCE PLUS SPECIAL BLADE N/AMEDROXYPROGESTERONE 10 MG TAB N/AMEDROXYPROGESTERONE 150 MG/ML N/AMEDROXYPROGESTERONE 2.5 MG TAB N/AMEDROXYPROGESTERONE 5 MG TAB N/AMEFLOQUINE HCL 250 MG TABLET N/AMEGA MULTI FOR MEN TABLET N/AMEGA MULTI FOR WOMEN TAB N/AMEGAVITE CAPLET N/AMEGAVITE GOLDEN YEARS CAPLET N/AMEGESTORL ACETATE POWDER N/AMEGESTROL 20 MG TABLET N/AMEGESTROL 40 MG TABLET N/AMEGESTROL 625 MG/5 ML SUSP N/AMEGESTROL ACET 40 MG/ML SUSP N/AMEGESTROL ACET 400 MG/10 ML N/AMEGESTROL ACETATE POWDER N/AMEIJER GLUCOSE 4 GRAM TAB CHEW N/AMEIJER LANCETS N/AMEIJER UNIVERSAL 1 26G LANCETS N/AMELOXICAM 15 MG TABLET N/AMELOXICAM 7.5 MG TABLET N/AMENACTRA VIAL N/AMEPERIDINE 100 MG TABLET N/AMEPERIDINE 50 MG TABLET N/AMEPERIDINE HCL POWDER N/A

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MEPHYTON 5 MG TABLET N/AMERCAPTOPURINE 50 MG TABLET N/AMESALAMINE 1;000 MG SUPP N/AMESALAMINE 4 GM/60 ML ENEMA N/AMESALAMINE 4 GM/60 ML KIT N/AMESALAMINE 800 MG DR TABLET N/AMESALAMINE DR 400 MG CAPSULE N/AMESALAMINE ER 0.375 GRAM CAP N/AMESALAMINE POWDER N/AMESNEX 400 MG TABLET N/AMETAMUCIL MULTIHEALTH POWDER N/AMETAMUCIL POWDER N/AMETAMUCIL SUGAR-FREE POWDER N/AMETAPROTERENOL 10 MG/5 ML SYR N/AMETFORMIN ER 500 MG GASTRC-TB N/AMETFORMIN ER 500 MG OSMOTIC TB N/AMETFORMIN HCL 1;000 MG TABLET N/AMETFORMIN HCL 500 MG TABLET N/AMETFORMIN HCL 850 MG TABLET N/AMETFORMIN HCL ER 500 MG TABLET N/AMETFORMIN HCL ER 750 MG TABLET N/AMETHADONE 10 MG/5 ML SOLUTION N/AMETHADONE 10 MG/ML ORAL CONC N/AMETHADONE 5 MG/5 ML SOLUTION N/AMETHADONE HCL 10 MG TABLET N/AMETHADONE HCL 5 MG TABLET N/AMETHADONE HCL POWDER N/AMETHADONE INTENSOL 10 MG/ML N/AMETHAZOLAMIDE 25 MG TABLET N/AMETHAZOLAMIDE 50 MG TABLET N/AMETHAZOLAMIDE POWDER N/AMETHENAMINE HIPP 1 GM TABLET N/AMETHENAMINE MANDELATE POWD N/A

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METHENAMINE MD 1 GM TABLET N/AMETHENAMINE MD 500 MG TABLET N/AMETHIMAZOLE 10 MG TABLET N/AMETHIMAZOLE 5 MG TABLET N/AMETHIMAZOLE POWDER N/AMETHITEST 10 MG TABLET N/AMETHOCARBAMOL 500 MG TABLET N/AMETHOCARBAMOL 750 MG TABLET N/AMETHOTREXATE 1 GRAM/40 ML VIAL N/AMETHOTREXATE 2.5 MG TABLET N/AMETHOTREXATE 25 MG/ML VIAL N/AMETHOTREXATE 250 MG/10 ML VIAL N/AMETHOTREXATE 50 MG/2 ML VIAL N/AMETHYLDOPA 250 MG TABLET N/AMETHYLDOPA 500 MG TABLET N/AMETHYLDOPA-HCTZ 250-15 MG TAB N/AMETHYLDOPA-HCTZ 250-25 MG TAB N/AMETHYLPREDNISOLONE 16 MG TAB N/AMETHYLPREDNISOLONE 32 MG TAB N/AMETHYLPREDNISOLONE 4 MG DOSEPK N/AMETHYLPREDNISOLONE 4 MG TABLET N/AMETHYLPREDNISOLONE 40 MG/ML VL N/AMETHYLPREDNISOLONE 8 MG TAB N/AMETHYLPREDNISOLONE 80 MG/ML VL N/AMETHYLPREDNISOLONE POWDER N/AMETHYLPREDNISOLONE SS 1 GM VL N/AMETHYLTESTOSTERONE MICRO POWD N/AMETIPRANOLOL 0.3% EYE DROPS N/AMETOCLOPRAMIDE 10 MG TABLET N/AMETOCLOPRAMIDE 10 MG/10 ML SOL N/AMETOCLOPRAMIDE 5 MG TABLET N/AMETOCLOPRAMIDE 5 MG/5 ML SOLN N/AMETOCLOPRAMIDE HCL POWDER N/A

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METOLAZONE 10 MG TABLET N/AMETOLAZONE 2.5 MG TABLET N/AMETOLAZONE 5 MG TABLET N/AMETOPROLOL SUCC ER 100 MG TAB N/AMETOPROLOL SUCC ER 200 MG TAB N/AMETOPROLOL SUCC ER 25 MG TAB N/AMETOPROLOL SUCC ER 50 MG TAB N/AMETOPROLOL TARTRATE 100 MG TAB N/AMETOPROLOL TARTRATE 25 MG TAB N/AMETOPROLOL TARTRATE 50 MG TAB N/AMETOPROLOL TARTRATE POWDER N/AMETOPROLOL-HCTZ 100-25 MG TAB N/AMETOPROLOL-HCTZ 100-50 MG TAB N/AMETOPROLOL-HCTZ 50-25 MG TAB N/AMETRONIDAZOLE 0.75% CREAM N/AMETRONIDAZOLE 0.75% LOTION N/AMETRONIDAZOLE 250 MG TABLET N/AMETRONIDAZOLE 375 MG CAPSULE N/AMETRONIDAZOLE 500 MG TABLET N/AMETRONIDAZOLE TOPICAL 0.75% GL N/AMETRONIDAZOLE TOPICAL 1% GEL N/AMETRONIDAZOLE VAGINAL 0.75% GL N/AMEXILETINE 150 MG CAPSULE N/AMEXILETINE 200 MG CAPSULE N/AMEXILETINE 250 MG CAPSULE N/AMIACALCIN 400 UNIT/2 ML VIAL N/AMI-ACID GAS 80 MG TAB CHEW N/AMICONAZOLE 2% TOPICAL CREAM N/AMICONAZOLE 2% VAGINAL CREAM N/AMICONAZOLE 3 COMBO PACK N/AMICONAZOLE 3 KIT N/AMICONAZOLE 7 100 MG VAG SUPP N/AMICONAZOLE 7 CREAM N/A

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MICONAZOLE-7 CREAM N/AMICRHOGAM ULTRA-FILTD PLUS SYR N/AMICRO THIN 33G LANCETS N/AMICROCHAMBER N/AMICROGESTIN 21 1.5-30 TAB N/AMICROGESTIN 21 1-20 TABLET N/AMICROGESTIN FE 1.5-30 TAB N/AMICROGESTIN FE 1-20 TABLET N/AMICROLET 2 LANCING DEVICE N/AMICROLET LANCETS N/AMICROLET NEXT LANCING DEVICE N/AMICROLIFE PEAK FLOW METER N/AMICROSPACER FOR AEROSOL DEVICE N/AMIDODRINE HCL 10 MG TABLET N/AMIDODRINE HCL 2.5 MG TABLET N/AMIDODRINE HCL 5 MG TABLET N/AMIGRANAL NASAL SPRAY N/AMILLTRIUM SENIOR MULTIVIT TAB N/AMINI LANCING DEVICE N/AMINI WRIGHT PEAK FLOW METER N/AMINITRAN 0.1 MG/HR PATCH N/AMINITRAN 0.2 MG/HR PATCH N/AMINITRAN 0.4 MG/HR PATCH N/AMINITRAN 0.6 MG/HR PATCH N/AMINI-WRIGHT PEAK FLOW METER N/AMINOCYCLINE 100 MG CAPSULE N/AMINOCYCLINE 50 MG CAPSULE N/AMINOCYCLINE 75 MG CAPSULE N/AMINOCYCLINE ER 105 MG TABLET N/AMINOCYCLINE ER 80 MG TABLET N/AMINOCYCLINE HCL POWDER N/AMINOXIDIL 10 MG TABLET N/AMINOXIDIL 2.5 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

MINT CHOCOLATE CHIP FLAVOR LIQ N/AMINTOX PLUS TABLET CHEWABLE N/AMIRALAX POWDER N/AMIRALAX POWDER PACKET N/AMIRENA 52 MG SYSTEM N/AMISOPROSTOL 100 MCG TABLET N/AMISOPROSTOL 200 MCG TABLET N/AM-M-R II VACCINE VIAL N/AM-M-R II VACCINE WITH DILUENT N/AMOEXIPRIL HCL 15 MG TABLET N/AMOEXIPRIL HCL 7.5 MG TABLET N/AMOMETASONE FUROATE 0.1% CREAM N/AMOMETASONE FUROATE 0.1% OINT N/AMOMETASONE FUROATE 0.1% SOLN N/AMONISTAT 7 COMBINATION PACK N/AMONOCAPS TABLET N/AMONOJECT 0.5 ML SYRN 28GX1/2'' N/AMONOJECT 1 ML SYRN 27X1/2'' N/AMONOJECT 1 ML SYRN 28GX1/2'' N/AMONOJECT INSUL SYR U100 N/AMONOJECT INSUL SYR U100 0.5 ML N/AMONOJECT INSUL SYR U100 1 ML N/AMONOJECT INSULIN SYR 0.3 ML N/AMONOJECT INSULIN SYR 0.5 ML N/AMONOJECT INSULIN SYR 1 ML N/AMONOJECT INSULIN SYR U-100 N/AMONOJECT INSULIN SYRN 3/10 ML N/AMONOJECT SYRINGE 0.3 ML N/AMONOJECT SYRINGE 0.5 ML N/AMONOJECT SYRINGE 1 ML N/AMONOJECT SYRINGE 3 ML 22GX1'' N/AMONOLET 21G LANCETS N/AMONOLET THIN 28G LANCETS N/A

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MONO-LINYAH 28 TABLET N/AMONTELUKAST SOD 10 MG TABLET N/AMONTELUKAST SOD 4 MG GRANULES N/AMONTELUKAST SOD 4 MG TAB CHEW N/AMONTELUKAST SOD 5 MG TAB CHEW N/AMORE-DOPHILUS POWDER N/AMORPHINE SULF 10 MG SUPPOS N/AMORPHINE SULF 10 MG/5 ML SOLN N/AMORPHINE SULF 100 MG/5 ML CONC N/AMORPHINE SULF 20 MG SUPPOS N/AMORPHINE SULF 20 MG/5 ML SOLN N/AMORPHINE SULF 30 MG SUPPOS N/AMORPHINE SULF 5 MG SUPPOS N/AMORPHINE SULF ER 100 MG TABLET N/AMORPHINE SULF ER 15 MG TABLET N/AMORPHINE SULF ER 200 MG TABLET N/AMORPHINE SULF ER 30 MG TABLET N/AMORPHINE SULF ER 60 MG TABLET N/AMORPHINE SULFATE IR 15 MG TAB N/AMORPHINE SULFATE IR 30 MG TAB N/AMORPHINE SULFATE POWDER N/AMOTION RELIEF 25 MG TABLET N/AMOTION SICKNESS 25 MG TABLET N/AMOTION SICKNESS RELIEF TB CHEW N/AMOTION-TIME 25 MG TABLET CHEW N/AMOTRIN IB 200 MG CAPLET N/AMOVANTIK 12.5 MG TABLET N/AMOVANTIK 25 MG TABLET N/AMOVE IT ALONG 100 MG TABLET N/AMOZOBIL 24 MG/1.2 ML VIAL N/AMS GLUCOSE 4 GRAM TABLET CHEW N/AMS INS SYR 0.5 ML 29GX1/2'' N/AMS INS SYR 1 ML 29GX1/2'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

MS INS SYRINGE 1 ML 30GX1/2'' N/AMS INSUL SYR 0.3 ML 31GX5/16'' N/AMS INSUL SYR 0.5 ML 30GX1/2'' N/AMS INSUL SYR 0.5 ML 31GX5/16'' N/AMS INSULIN SYR 0.3 ML 29GX1/2'' N/AMS INSULIN SYR 1 ML 31GX5/16'' N/AMS INSULIN SYRINGE 0.3 ML N/AMS PEN NEEDLE 6MM 31G N/AMS QUICK DISSOLVE GLUCOSE TAB N/AMUCINEX D ER 1;200-120 MG TAB N/AMUCINEX D ER 600-60 MG TABLET N/AMUCINEX ER 1;200 MG TABLET N/AMUCINEX ER 600 MG TABLET N/AMUCINEX FAST-MAX DM MAX LIQUID N/AMUCINEX SINUS-MAX NASAL SPRAY N/AMUCUS ER 600 MG TABLET N/AMUCUS RELIEF CONGEST-COUGH LIQ N/AMUCUS RELIEF DM MAX LIQUID N/AMUCUS RELIEF ER 600 MG TABLET N/AMULPLETA 3 MG TABLET N/AMULTAQ 400 MG TABLET N/AMULTI COMPLETE-IRON TABLET N/AMULTI FOR HER TABLET N/AMULTI-DAY PLUS IRON TABLET N/AMULTI-DAY PLUS MINERALS TABLET N/AMULTI-DELYN WITH IRON LIQUID N/AMULTI-LANCET DEVICE 2 KIT N/AMULTILEX TABLET N/AMULTILEX T-M TABLET N/AMULTIPLE VITAMIN WITH IRON TAB N/AMULTIPLE VITAMIN W-MINERALS TB N/AMULTISTIX 10 SG REAGENT STRIPS N/AMULTISTIX 5 STRIPS N/A

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MULTISTIX 7 REAGENT STRIPS N/AMULTISTIX 8 SG REAGENT STRIPS N/AMULTISTIX 9 REAGENT STRIPS N/AMULTISTIX 9 SG REAGENT STRIPS N/AMULTISTIX REAGENT STRIPS N/AMULTIVIT-FLUOR 0.25 MG TAB CHW N/AMULTIVIT-FLUOR 0.25 MG/ML DROP N/AMULTIVIT-FLUOR 0.5 MG TAB CHEW N/AMULTIVIT-FLUOR 0.5 MG/ML DROP N/AMULTIVIT-FLUORIDE 1 MG TAB CHW N/AMULTIVIT-IRON-FLUOR 0.25 MG/ML N/AMULTIVIT-MINERALS TABLET N/AMUPIROCIN 2% OINTMENT N/AMVC-FLUORIDE 0.25 MG TAB CHEW N/AMVC-FLUORIDE 0.5 MG TAB CHEW N/AMVC-FLUORIDE 1 MG TAB CHEW N/AMX-SOL SYRUP N/AMY WAY 1.5 MG TABLET N/AMYCOPHENOLATE 200 MG/ML SUSP N/AMYCOPHENOLATE 250 MG CAPSULE N/AMYCOPHENOLATE 500 MG TABLET N/AMYCOPHENOLATE 500 MG VIAL N/AMYGLUCOHEALTH 30G LANCETS N/AMYORISAN 10 MG CAPSULE N/AMYORISAN 20 MG CAPSULE N/AMYORISAN 30 MG CAPSULE N/AMYORISAN 40 MG CAPSULE N/ANABUMETONE 500 MG TABLET N/ANABUMETONE 750 MG TABLET N/ANADOLOL 20 MG TABLET N/ANADOLOL 40 MG TABLET N/ANADOLOL 80 MG TABLET N/ANADOLOL POWDER N/A

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NADOLOL-BENDROFLU 80-5 MG TAB N/ANAPROXEN 125 MG/5 ML SUSPEN N/ANAPROXEN 250 MG TABLET N/ANAPROXEN 375 MG TABLET N/ANAPROXEN 500 MG KIT N/ANAPROXEN 500 MG TABLET N/ANAPROXEN DR 375 MG TABLET N/ANAPROXEN DR 500 MG TABLET N/ANAPROXEN POWDER N/ANAPROXEN SODIUM 275 MG TAB N/ANAPROXEN SODIUM POWDER N/ANARAMIN 12.5 MG ORAL SOLUTION N/ANARATRIPTAN HCL 1 MG TABLET N/ANARATRIPTAN HCL 2.5 MG TABLET N/ANASACORT ALLERGY 24HR SPRAY N/ANASAL ALLERGY 24HR SPRAY N/ANASAL DECONGESTANT 0.05% SPRAY N/ANASAL RELIEF 0.05% SPRAY N/ANASAL SPRAY 0.05% N/ANASAL SPRAY ORIGINAL 0.05% N/ANASCOBAL 500 MCG NASAL SPRAY N/ANATAZIA 28 TABLET N/ANATEGLINIDE 120 MG TABLET N/ANATEGLINIDE 60 MG TABLET N/ANATURAL BITTERNESS MASKING POW N/ANATURAL FIBER LAX POWDER N/ANATURAL FIBER LAXATIVE CAPSULE N/ANATURAL FIBER LAXATIVE POWDER N/ANATURAL FIBER POWDER N/ANATURE-THROID 130 MG TABLET N/ANECON 0.5-35-28 TABLET N/ANEO-BACIT-POLY-HC EYE OINTMENT N/ANEOMYC-BACIT-POLYMIX EYE OINT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

NEOMYCIN 500 MG TABLET N/ANEOMYCIN-POLY-HC EYE DROPS N/ANEOMYCIN-POLYMYXIN-HC EAR SOLN N/ANEOMYCIN-POLYMYXIN-HC EAR SUSP N/ANEOMYC-POLYM-DEXAMET EYE OINTM N/ANEOMYC-POLYM-DEXAMETH EYE DROP N/ANEOMYC-POLYM-GRAMICID EYE DROP N/ANEO-POLYCIN EYE OINTMENT N/ANEO-POLYCIN HC EYE OINTMENT N/ANEOTUSS-D LIQUID N/ANEULASTA 6 MG/0.6 ML SYRINGE N/ANEUPOGEN 300 MCG/ML VIAL N/ANEUPOGEN 480 MCG/1.6 ML VIAL N/ANEVIRAPINE 200 MG TABLET N/ANEVIRAPINE 50 MG/5 ML SUSP N/ANEVIRAPINE ER 100 MG TABLET N/ANEVIRAPINE ER 400 MG TABLET N/ANEXIUM 24HR 20 MG CAPSULE N/ANEXIUM DR 10 MG PACKET N/ANEXIUM DR 2.5 MG PACKET N/ANEXIUM DR 20 MG CAPSULE N/ANEXIUM DR 20 MG PACKET N/ANEXIUM DR 40 MG CAPSULE N/ANEXIUM DR 40 MG PACKET N/ANEXIUM DR 5 MG PACKET N/ANEXPLANON 68 MG IMPLANT N/ANIACIN 100 MG TABLET N/ANIACIN 250 MG TABLET N/ANIACIN 50 MG TABLET N/ANIACIN 500 MG CAPSULE SA N/ANIACIN 750 MG TABLET SA N/ANIACIN ER 250 MG CAPSULE N/ANIACIN ER 250 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

NIACIN ER 500 MG CAPLET N/ANIACIN SA 250 MG CAPSULE N/ANIACIN TR 250 MG CAPSULE N/ANIACIN TR 250 MG TABLET N/ANIACIN TR 500 MG CAPSULE N/ANIACIN TR 500 MG TABLET N/ANICADAN ZX TABLET N/ANICARDIPINE 20 MG CAPSULE N/ANICARDIPINE 30 MG CAPSULE N/ANICE DISTILLED WATER N/ANICOTINIC ACID POWDER N/ANIFEDIPINE 10 MG CAPSULE N/ANIFEDIPINE 20 MG CAPSULE N/ANIFEDIPINE ER 30 MG TABLET N/ANIFEDIPINE ER 60 MG TABLET N/ANIFEDIPINE ER 90 MG TABLET N/ANIFEDIPINE POWDER N/ANIGHT ALLERGY RLF 25 MG CAPLET N/ANIKKI 3 MG-0.02 MG TABLET N/ANIMODIPINE 30 MG CAPSULE N/ANISOLDIPINE ER 17 MG TABLET N/ANISOLDIPINE ER 20 MG TABLET N/ANISOLDIPINE ER 25.5 MG TABLET N/ANISOLDIPINE ER 30 MG TABLET N/ANISOLDIPINE ER 34 MG TABLET N/ANISOLDIPINE ER 40 MG TABLET N/ANISOLDIPINE ER 8.5 MG TABLET N/ANITISINONE 10 MG CAPSULE N/ANITISINONE 2 MG CAPSULE N/ANITISINONE 5 MG CAPSULE N/ANITRO-BID 2% OINTMENT N/ANITRO-DUR 0.1 MG/HR PATCH N/ANITRO-DUR 0.2 MG/HR PATCH N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

NITRO-DUR 0.3 MG/HR PATCH N/ANITRO-DUR 0.4 MG/HR PATCH N/ANITRO-DUR 0.6 MG/HR PATCH N/ANITRO-DUR 0.8 MG/HR PATCH N/ANITROFURANTOIN 25 MG/5 ML SUSP N/ANITROFURANTOIN MCR 100 MG CAP N/ANITROFURANTOIN MCR 50 MG CAP N/ANITROFURANTOIN MONO-MCR 100 MG N/ANITROGLYCERIN 0.1 MG/HR PATCH N/ANITROGLYCERIN 0.2 MG/HR PATCH N/ANITROGLYCERIN 0.3 MG TABLET SL N/ANITROGLYCERIN 0.4 MG TABLET SL N/ANITROGLYCERIN 0.4 MG/HR PATCH N/ANITROGLYCERIN 0.6 MG TABLET SL N/ANITROGLYCERIN 0.6 MG/HR PATCH N/ANITRO-TIME ER 2.5 MG CAPSULE N/ANITRO-TIME ER 6.5 MG CAPSULE N/ANITRO-TIME ER 9 MG CAPSULE N/ANIVANEX DMX TABLET N/ANIZATIDINE 15 MG/ML SOLUTION N/ANIZATIDINE 150 MG CAPSULE N/ANIZATIDINE 300 MG CAPSULE N/ANO DRIP 0.05% NASAL SPRAY N/ANOBLE FORMULA HC 1% CREAM N/ANON-ASPIRIN 160 MG/5 ML ELIX N/ANON-ASPIRIN 325 MG TABLET N/ANON-ASPIRIN 500 MG CAPLET N/ANON-ASPIRIN 500 MG TABLET N/ANON-ASPIRIN 80 MG TAB CHEW N/ANORA-BE TABLET N/ANORETH-ESTRAD-FE 1-0.02(21)-75 N/ANORETHIND-ETH ESTRAD 0.5-2.5 N/ANORETHIND-ETH ESTRAD 1-0.02 MG N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

NORETHINDRONE 0.35 MG TABLET N/ANORETHINDRONE 5 MG TABLET N/ANORETHINDRONE ACETATE POWDER N/ANORETHIN-ESTRA-FE 0.8-0.025 MG N/ANORETHIN-ETH ESTRAD 1 MG-5 MCG N/ANORG-EE 0.18-0.215-0.25/0.025 N/ANORG-EE 0.18-0.215-0.25/0.035 N/ANORGESTIMATE-EE 0.25-0.035 MG N/ANORG-ETHIN ESTRA 0.25-0.035 MG N/ANORTEMP 80 MG/0.8 ML DROP N/ANORTREL 0.5-35-28 TABLET N/ANORTREL 1-35 21 TABLET N/ANORTREL 1-35 28 TABLET N/ANORTREL 7-7-7-28 TABLET N/ANORVIR 100 MG POWDER PACKET N/ANORVIR 100 MG TABLET N/ANORVIR 80 MG/ML SOLUTION N/ANOVA SAFETY 23G LANCETS N/ANOVA SAFETY 28G LANCETS N/ANOVA SUREFLEX LANCING DEVICE N/ANOVA SUREFLEX THIN LANCETS N/ANOVAFERRUM PED MULTIVIT-IRON N/ANOVOLIN 70-30 100 UNIT/ML VIAL N/ANOVOLIN N 100 UNIT/ML VIAL N/ANOVOLIN R 100 UNIT/ML VIAL N/ANP THYROID 30 MG TABLET N/ANP THYROID 60 MG TABLET N/ANP THYROID 90 MG TABLET N/ANULEV 0.125 MG CHEWABLE MELT N/ANULOJIX 250 MG VIAL N/ANUVARING VAGINAL RING N/ANYAMYC 100;000 UNITS/GM POWDER N/ANYSTATIN 100;000 UNIT/GM CREAM N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

NYSTATIN 100;000 UNIT/GM OINT N/ANYSTATIN 100;000 UNIT/GM POWD N/ANYSTATIN 100;000 UNIT/ML SUSP N/ANYSTATIN 150 MILLION UNIT PWD N/ANYSTATIN 50 MILLION UNIT PWD N/ANYSTATIN 500 MILLION UNIT PWD N/ANYSTATIN 500;000 UNIT ORAL TAB N/ANYSTATIN 500;000 UNIT/5 ML SUS N/ANYSTOP 100;000 UNITS/GM POWDER N/AOCELLA 3 MG-0.03 MG TABLET N/AOCREVUS 300 MG/10 ML VIAL N/AOCTREOTIDE 1;000 MCG/5 ML VIAL N/AOCTREOTIDE 1;000 MCG/ML VIAL N/AOCTREOTIDE 5;000 MCG/5 ML VIAL N/AOCTREOTIDE ACET 0.05 MG/ML VL N/AOCTREOTIDE ACET 100 MCG/ML VL N/AOCTREOTIDE ACET 200 MCG/ML VL N/AOCTREOTIDE ACET 50 MCG/ML VIAL N/AOCTREOTIDE ACET 500 MCG/ML VL N/AOCUTABS TABLET N/AOCUVITE EYE PLUS MULTI TABLET N/AOCUVITE WITH LUTEIN TABLET N/AODEFSEY TABLET N/AOFLOXACIN 0.3% EAR DROPS N/AOFLOXACIN 0.3% EYE DROPS N/AOFLOXACIN 400 MG TABLET N/AOLIVE (SWEET) OIL N/AOLIVE OIL N/AOMEGA 3 1;000 MG SOFTGEL N/AOMEGA 3 FISH OIL SOFTGEL N/AOMEGA-3 1;000 MG SOFTGEL N/AOMEGA-3 FISH OIL 1;000 MG SFGL N/AOMEGA-3 FISH OIL 1;000 MG SFTG N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

OMEGA-3 FISH OIL 1;200 MG SFGL N/AOMEGA-3 FISH OIL 1;400 MG SFGL N/AOMEGA-3 FISH OIL EC 1;000 MG N/AOMEGA-3 FISH OIL SOFTGEL N/AOMEPRAZOLE DR 20 MG TABLET N/AOMEPRAZOLE MAG DR 20 MG CAP N/AOMEPRAZOLE MAG DR 20.6 MG CAP N/AOMEPRAZOLE-BICARB 20-1;100 CAP N/AOMEPRAZOLE-BICARB 40-1;100 CAP N/AOMERA CAPSULE N/AOMNITROPE 10 MG/1.5 ML CRTG N/AOMNITROPE 5 MG/1.5 ML CRTG N/AOMNITROPE 5.8 MG VIAL N/AON CALL 30G LANCET N/AON CALL LANCING DEVICE N/AON CALL PLUS 30G LANCET N/AON CALL PLUS LANCING DEVICE N/AONCOVITE TABLET N/AONDANSETRON 4 MG/5 ML SOLUTION N/AONDANSETRON HCL 24 MG TABLET N/AONDANSETRON HCL 4 MG TABLET N/AONDANSETRON HCL 8 MG TABLET N/AONDANSETRON ODT 4 MG TABLET N/AONDANSETRON ODT 8 MG TABLET N/AONE DAILY COMPLETE TABLET N/AONE DAILY FOR MEN 50+ ADV TAB N/AONE DAILY FOR MEN TABLET N/AONE DAILY FOR WOMEN 50+ ADV TB N/AONE DAILY FOR WOMEN TABLET N/AONE DAILY HEALTHY WEIGHT TAB N/AONE DAILY MAXIMUM TABLET N/AONE DAILY MEN'S 50+ TABLET N/AONE DAILY MEN'S HEALTH TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ONE DAILY MULTIVITAMIN-IRON TB N/AONE DAILY MULTIVIT-MINERAL TAB N/AONE DAILY PLUS IRON TABLET N/AONE DAILY TABLET N/AONE DAILY WITH IRON-CALCIUM TB N/AONE DAILY WITH MINERALS TABLET N/AONE DAILY WOMEN 50 PLUS TAB N/AONE DAILY WOMENS 50 PLUS TAB N/AONE DAILY WOMEN'S 50+ TABLET N/AONE DAILY WOMEN'S TABLET N/AONE-A-DAY ENERGY TABLET N/AONE-A-DAY MENOPAUSE FORMULA TB N/AONE-A-DAY MEN'S 50 PLUS TABLET N/AONE-A-DAY MEN'S TABLET N/AONE-A-DAY TEEN ADVANTAGE TAB N/AONE-DAILY MULTI-VIT-IRON TAB N/AONETOUCH DELICA 30G LANCETS N/AONETOUCH DELICA 33G LANCETS N/AONETOUCH DELICA LANCING DEV N/AONETOUCH DELICA PLUS 30G LANCT N/AONETOUCH DELICA PLUS 33G LANCT N/AONETOUCH DELICA PLUS LANC DEV N/AONETOUCH ULTRA BLUE TEST STRP N/AONETOUCH ULTRA CONTROL SOLN N/AONETOUCH ULTRAMINI METER N/AONETOUCH ULTRASOFT LANCETS N/AONETOUCH VERIO HIGH CNTRL SOLN N/AONETOUCH VERIO IQ METER N/AONETOUCH VERIO MID CNTRL SOLN N/AONETOUCH VERIO TEST STRIP N/AON-THE-GO 30G LANCETS N/AOPCICON ONE-STEP 1.5 MG TABLET N/AOPTICHAMBER DIAMOND VHC N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

OPTICHAMBER DIAMOND W-LRG MASK N/AOPTICHAMBER DIAMOND W-MED MASK N/AOPTICHAMBER DIAMOND W-SML MASK N/AOPTIMAL D3 50;000 UNIT CAPSULE N/AORA PLUS SUSPENSION N/AORA SWEET ORAL SYRUP N/AORA-BLEND SF SUSPENSION N/AORA-BLEND SUSPENSION N/AORAL MIX SF VEHICLE N/AORAL MIX VEHICLE N/AORAL SUSPEND VEHICLE N/AORAL SYRUP SF VEHICLE N/AORAL SYRUP VEHICLE N/AORANGE CONCENTRATE FLAVOR LIQ N/AORANGE CREAM FLAVOR LIQUID N/AORANGE FLAVOR LIQUID N/AORANGE FLAVOR POWDER N/AORANGE OIL N/AORANGE OIL FLAVOR N/AORA-PLUS SUSPENDING VEHICLE N/AORA-SWEET ORAL SYRUP N/AORA-SWEET SF SYRUP N/AORA-SWEET-SF SYRUP N/AORPHENADRINE ER 100 MG TABLET N/AORSYTHIA-28 TABLET N/AORTHO-TABS N/AOSCIMIN 0.125 MG TABLET N/AOSCIMIN SL 0.125 MG TABLET N/AOSELTAMIVIR 6 MG/ML SUSPENSION N/AOSELTAMIVIR PHOS 30 MG CAPSULE N/AOSELTAMIVIR PHOS 45 MG CAPSULE N/AOSELTAMIVIR PHOS 75 MG CAPSULE N/AOXAPROZIN 600 MG CAPLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

OXAPROZIN 600 MG TABLET N/AOXYBUTYNIN 5 MG TABLET N/AOXYBUTYNIN 5 MG/5 ML SYRUP N/AOXYBUTYNIN CHLORIDE POWDER N/AOXYBUTYNIN CL ER 10 MG TABLET N/AOXYBUTYNIN CL ER 15 MG TABLET N/AOXYBUTYNIN CL ER 5 MG TABLET N/AOXYCODON-ACETAMINOPHEN 2.5-325 N/AOXYCODON-ACETAMINOPHEN 7.5-325 N/AOXYCODONE HCL 10 MG TABLET N/AOXYCODONE HCL 100 MG/5 ML CONC N/AOXYCODONE HCL 15 MG TABLET N/AOXYCODONE HCL 20 MG TABLET N/AOXYCODONE HCL 30 MG TABLET N/AOXYCODONE HCL 5 MG CAPSULE N/AOXYCODONE HCL 5 MG TABLET N/AOXYCODONE HCL 5 MG/5 ML SOLN N/AOXYCODONE HCL POWDER N/AOXYCODONE-ACETAMINOPHEN 10-325 N/AOXYCODONE-ACETAMINOPHEN 5-325 N/AOXYMORPHONE HCL ER 10 MG TAB N/AOXYMORPHONE HCL ER 15 MG TAB N/AOXYMORPHONE HCL ER 20 MG TAB N/AOXYMORPHONE HCL ER 30 MG TAB N/AOXYMORPHONE HCL ER 40 MG TAB N/AOXYMORPHONE HCL ER 5 MG TABLET N/AOXYMORPHONE HCL ER 7.5 MG TAB N/AOZEMPIC 0.25-0.5 MG DOSE PEN N/AOZEMPIC 1 MG DOSE PEN N/APACERONE 100 MG TABLET N/APACERONE 200 MG TABLET N/APACERONE 400 MG TABLET N/APAIN RELIEF 160 MG/5 ML LIQUID N/A

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PAIN RELIEF 325 MG TABLET N/APAIN RELIEF 500 MG CAPLET N/APAIN RELIEF 500 MG GELCAP N/APAIN RELIEF 500 MG TABLET N/APAIN RELIEF ADULT 500 MG/15 ML N/APAIN RELIEF ER 650 MG CAPLET N/APAIN RELIEVER 325 MG TABLET N/APAIN RELIEVER 500 MG CAPLET N/APAIN RELIEVER 500 MG GELCAP N/APAIN RELIEVER 500 MG TABLET N/APAIN RELIEVER ER 650 MG CAPLET N/APALYNZIQ 10 MG/0.5 ML SYRINGE N/APALYNZIQ 2.5 MG/0.5 ML SYRINGE N/APALYNZIQ 20 MG/ML SYRINGE N/APANCREAZE DR 10;500 UNIT CAP N/APANCREAZE DR 16;800 UNIT CAP N/APANCREAZE DR 21;000 UNIT CAP N/APANCREAZE DR 4;200 UNIT CAP N/APANTOPRAZOLE SOD DR 20 MG TAB N/APANTOPRAZOLE SOD DR 40 MG TAB N/APARAGARD T 380-A IUD N/APARICALCITOL 1 MCG CAPSULE N/APARICALCITOL 2 MCG CAPSULE N/APARICALCITOL 4 MCG CAPSULE N/APAROEX 0.12% ORAL RINSE N/APAROMOMYCIN 250 MG CAPSULE N/APARVLEX TABLET N/APASSION FRUIT FLAVOR POWDER N/APC SUPER THIN 30G LANCETS N/APC UNIFINE PENTIPS 12MM NEEDLE N/APC UNIFINE PENTIPS 6MM NEEDLE N/APC UNIFINE PENTIPS 8MM NEEDLE N/APCCA POLYGLYCOL TROCHE BASE N/A

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PCCA T3 SODIUM DILUTION POWD N/APCCA-PLUS ORAL SUSP VEHICLE N/APEACH FLAVOR LIQUID N/APEAK-AIR PEAK FLOW METER N/APEANUT BUTTER FLAVOR LIQUID N/APEG 3350-ELECTROLYTE SOLUTION N/APEG-3350 AND ELECTROLYTES SOLN N/APEGASYS 180 MCG/0.5 ML SYRINGE N/APEGASYS 180 MCG/ML VIAL N/APEGINTRON 50 MCG KIT N/APEN NEEDLE 31G 8MM N/APEN NEEDLE 31G X 8MM N/APEN NEEDLES 6MM 31G N/APENICILLAMINE POWDER N/APENICILLAMINE(D-) POWDER N/APENICILLIN VK 125 MG/5 ML SOLN N/APENICILLIN VK 250 MG TABLET N/APENICILLIN VK 250 MG/5 ML SOLN N/APENICILLIN VK 500 MG TABLET N/APENTIPS PEN NEEDLE 31GX5/16'' N/APENTOXIFYLLINE ER 400 MG TAB N/APEPPERMINT FLAVOR N/APERINDOPRIL ERBUMINE 2 MG TAB N/APERINDOPRIL ERBUMINE 4 MG TAB N/APERINDOPRIL ERBUMINE 8 MG TAB N/APERIOGARD 0.12% ORAL RINSE N/APERMETHRIN 5% CREAM N/APERSONAL BEST PEAK FLOW MTR N/APETROLATUM BASE OINTMENT N/APETROLATUM JELLY WHITE N/APETROLEUM JELLY 100% PURE N/APETROLEUM JELLY LIP TREATMENT N/APETROLEUM JELLY SHEA BUTTER N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PHARBECHLOR 4 MG TABLET N/APHARBEDRYL 25 MG CAPSULE N/APHARBEDRYL 50 MG CAPSULE N/APHARBETOL 325 MG TABLET N/APHARBETOL 500 MG CAPLET N/APHARBETOL 500 MG TABLET N/APHARM CHOICE ALCOHOL PREP PADS N/APHARMACIST CHOICE 28G LANCETS N/APHARMACIST CHOICE 30G LANCETS N/APHARMACIST CHOICE 33G LANCETS N/APHENAZOPYRIDINE 100 MG TAB N/APHENAZOPYRIDINE 200 MG TAB N/APHENAZOPYRIDINE HCL POWDER N/APHENOBARBITAL 100 MG TABLET N/APHENOBARBITAL 15 MG TABLET N/APHENOBARBITAL 16.2 MG TABLET N/APHENOBARBITAL 20 MG/5 ML ELIX N/APHENOBARBITAL 20 MG/5 ML SOLN N/APHENOBARBITAL 30 MG TABLET N/APHENOBARBITAL 32.4 MG TABLET N/APHENOBARBITAL 60 MG TABLET N/APHENOBARBITAL 64.8 MG TABLET N/APHENOBARBITAL 97.2 MG TABLET N/APHENOBARBITAL POWDER N/APHENYTOIN 125 MG/5 ML SUSP N/APHENYTOIN 50 MG INFATAB N/APHENYTOIN 50 MG TABLET CHEW N/APHENYTOIN SOD EXT 100 MG CAP N/APHILITH 0.4-0.035 MG TABLET N/APHILLIPS' LAX LIQUI-GELS N/APHYTOMULTI TABLET N/APHYTONADIONE 5 MG TABLET N/APIFELTRO 100 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PIKO 1 FLOW METER N/APILOCARPINE 1% EYE DROPS N/APILOCARPINE 2% EYE DROPS N/APILOCARPINE 4% EYE DROPS N/APILOCARPINE HCL 5 MG TABLET N/APILOCARPINE HCL 7.5 MG TABLET N/APIMECROLIMUS 1% CREAM N/APIMTREA 28 DAY TABLET N/APINA COLADA FLAVOR LIQUID N/APINDOLOL 10 MG TABLET N/APINDOLOL 5 MG TABLET N/APINEAPPLE FLAVOR LIQUID N/APINK BISMUTH 262 MG/15 ML SUSP N/APINK BISMUTH MAX-STR SUSP N/APIOGLITAZONE HCL 15 MG TABLET N/APIOGLITAZONE HCL 30 MG TABLET N/APIOGLITAZONE HCL 45 MG TABLET N/APIOGLITAZONE-GLIMEPIRIDE 30-2 N/APIOGLITAZONE-GLIMEPIRIDE 30-4 N/APIOGLITAZONE-METFORMIN 15-500 N/APIOGLITAZONE-METFORMIN 15-850 N/APIRMELLA 1-35 28 TABLET N/APIRMELLA 7-7-7-28 TABLET N/APIROXICAM 10 MG CAPSULE N/APIROXICAM 20 MG CAPSULE N/APIROXICAM POWDER N/APLAIN NIACIN 250 MG TABLET N/APLAIN NIACIN 500 MG TABLET N/APLAQUENIL 200 MG TABLET N/APNEUMOVAX 23 SYRINGE N/APNV PRENATAL PLUS MULTIVIT TAB N/APNV-DHA + DOCUSATE SOFTGEL N/APNV-DHA SOFTGEL N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PNV-OMEGA SOFTGEL N/APNV-SELECT TABLET N/APOCKET CHAMBER N/APOCKET PEAK FLOW METER N/APODOCON-25 LIQUID N/APODOFILOX 0.5% TOPICAL SOLN N/APOLYCIN EYE OINTMENT N/APOLYMYXIN B-TMP EYE DROPS N/APORTIA-28 TABLET N/APOTABA 500 MG CAPSULE N/APOTASSIUM CHLORIDE POWDER N/APOTASSIUM CITRATE ER 10 MEQ TB N/APOTASSIUM CITRATE ER 15 MEQ TB N/APOTASSIUM CITRATE ER 5 MEQ TAB N/APOTASSIUM CITRATE POWDER N/APOTASSIUM CL 10% (20 MEQ/15ML) N/APOTASSIUM CL 10% (40 MEQ/30ML) N/APOTASSIUM CL 20 MEQ PACKET N/APOTASSIUM CL ER 10 MEQ CAPSULE N/APOTASSIUM CL ER 10 MEQ TABLET N/APOTASSIUM CL ER 8 MEQ CAPSULE N/APOTASSIUM CL ER 8 MEQ TABLET N/APOTELIGEO 20 MG/5 ML VIAL N/APOWDERLAX POWDER N/APRALINES AND CREAM FLAVOR LIQ N/APRAMOSONE 1%-1% CREAM N/APRAVASTATIN SODIUM 10 MG TAB N/APRAVASTATIN SODIUM 20 MG TAB N/APRAVASTATIN SODIUM 40 MG TAB N/APRAVASTATIN SODIUM 80 MG TAB N/APRAZOSIN 1 MG CAPSULE N/APRAZOSIN 2 MG CAPSULE N/APRAZOSIN 5 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PRED MILD 0.12% EYE DROPS N/APREDNICARBATE 0.1% CREAM N/APREDNICARBATE 0.1% OINTMENT N/APREDNISOLONE 15 MG/5 ML SOLN N/APREDNISOLONE 5 MG/5 ML SOLN N/APREDNISOLONE AC 1% EYE DROP N/APREDNISOLONE ANHYDROUS POWDER N/APREDNISOLONE MICRONIZED POWDER N/APREDNISOLONE POWDER N/APREDNISOLONE SOD 1% EYE DROP N/APREDNISOLONE SOD PH 25 MG/5 ML N/APREDNISOLONE SOD PH POWDER N/APREDNISONE 1 MG TABLET N/APREDNISONE 10 MG TABLET N/APREDNISONE 2.5 MG TABLET N/APREDNISONE 20 MG TABLET N/APREDNISONE 5 MG TABLET N/APREDNISONE 5 MG/5 ML SOLUTION N/APREDNISONE 50 MG TABLET N/APREDNISONE INTENSOL 5 MG/ML N/APREDNISONE MICRONIZED POWDER N/APREF PLUS INS 0.3 ML 29GX1/2'' N/APREF PLUS SYR 0.5 ML 30GX5/16'' N/APREF PLUS SYRING 1 ML 29GX1/2'' N/APREFERRED PLUS 0.3 ML 30GX5/16 N/APREFERRED PLUS 0.5 ML 29GX1/2'' N/APREFERRED PLUS GLUCOSE TAB CHW N/APREFERRED PLUS LANCETS N/APREFERRED PLUS SYRINGE 0.5 ML N/APREFERRED PLUS SYRINGE 1 ML N/APREFERRED PLUS THIN LANCETS N/APREFPLS INS SYR 1 ML 30GX5/16'' N/APREMARIN 0.3 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PREMARIN 0.45 MG TABLET N/APREMARIN 0.625 MG TABLET N/APREMARIN 0.9 MG TABLET N/APREMARIN 1.25 MG TABLET N/APREMARIN VAGINAL CREAM-APPL N/APREMPHASE 0.625-5 MG TABLET N/APREMPRO 0.3 MG-1.5 MG TABLET N/APREMPRO 0.45-1.5 MG TABLET N/APREMPRO 0.625-2.5 MG TABLET N/APREMPRO 0.625-5 MG TABLET N/APRENATABS RX TABLET N/APRENATAL MULTI TABLET N/APRENATAL ONE DAILY TABLET N/APRENATAL VITAMIN PLUS LOW IRON N/APRENATAL VITAMIN TABLET N/APRENATE CHEWABLE TABLET N/APREP EASE ALCOHOL PADS N/APREPARATION H HC 1% CREAM N/APREPLUS CA-FE 27 MG-FA 1 MG TB N/APRES GEN LIQUID N/APRES GEN PEDIATRIC LIQUID N/APRESERVISION AREDS TABLET N/APRESSURE ACTIVATED 21G LANCETS N/APRESSURE ACTIVATED 28G LANCETS N/APREVACID 15 MG SOLUTAB N/APREVACID 30 MG SOLUTAB N/APREVALITE PACKET N/APREVALITE POWDER N/APREVIFEM TABLET N/APREZCOBIX 800 MG-150 MG TABLET N/APREZISTA 100 MG/ML SUSPENSION N/APREZISTA 150 MG TABLET N/APREZISTA 600 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PREZISTA 75 MG TABLET N/APREZISTA 800 MG TABLET N/APRIFTIN 150 MG TABLET N/APRIMAQUINE 26.3 MG TABLET N/APRIMIDONE 250 MG TABLET N/APRIMIDONE 50 MG TABLET N/APRO COMFORT 30G LANCETS N/APRO COMFORT 31G LANCET N/APRO COMFORT ALCOHOL 70% PADS N/APROBENECID 500 MG TABLET N/APRO-CAL TABLET N/APROCERV HP TABLET N/APROCHAMBER HOLDING CHAMBER N/APROCHLORPERAZINE 10 MG TAB N/APROCHLORPERAZINE 25 MG SUPP N/APROCHLORPERAZINE 5 MG TABLET N/APROCHLORPERAZINE MAL POWDER N/APROCRIT 2;000 UNITS/ML VIAL N/APROCRIT 20;000 UNITS/ML VIAL N/APROCRIT 3;000 UNITS/ML VIAL N/APROCRIT 4;000 UNITS/ML VIAL N/APROCRIT 40;000 UNITS/ML VIAL N/APROCTOFOAM-HC 1%-1% FOAM N/APROCTO-MED HC 2.5% CREAM N/APROCTO-PAK 1% CREAM N/APROCTOSOL-HC 2.5% CREAM N/APROCTOZONE-HC 2.5% CREAM N/APRODIGY INS SYR 1ML 28GX1/2'' N/APRODIGY LANCING DEVICE N/APRODIGY PRESSURE ACTIVATED 28G N/APRODIGY SAFETY 26G LANCETS N/APRODIGY SYRNG 0.5 ML 31GX5/16'' N/APRODIGY SYRNGE 0.3ML 31GX5/16'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PRODIGY TWIST TOP 28G LANCET N/APROMETHAZINE 12.5 MG SUPPOS N/APROMETHAZINE 12.5 MG TABLET N/APROMETHAZINE 25 MG SUPPOSITORY N/APROMETHAZINE 25 MG TABLET N/APROMETHAZINE 50 MG SUPPOSITORY N/APROMETHAZINE 50 MG TABLET N/APROMETHAZINE 6.25 MG/5 ML SOLN N/APROMETHAZINE 6.25 MG/5 ML SYRP N/APROMETHAZINE-CODEINE SYRUP N/APROMETHAZINE-DM SOLUTION N/APROMETHAZINE-DM SYRUP N/APROMETHAZINE-PE-CODEINE SYRUP N/APROMETHAZINE-PHENYLEPHRINE SYR N/APROMETHEGAN 12.5 MG SUPPOS N/APROMETHEGAN 25 MG SUPPOSITORY N/APROMETHEGAN 50 MG SUPPOSITORY N/APROMOLAXIN 100 MG TABLET N/APROPAFENONE HCL 150 MG TABLET N/APROPAFENONE HCL 225 MG TAB N/APROPAFENONE HCL 300 MG TAB N/APROPAFENONE HCL ER 225 MG CAP N/APROPAFENONE HCL ER 325 MG CAP N/APROPAFENONE HCL ER 425 MG CAP N/APROPANTHELINE 15 MG TABLET N/APROPANTHELINE BROMIDE POWDER N/APROPRANOLOL 10 MG TABLET N/APROPRANOLOL 20 MG TABLET N/APROPRANOLOL 20 MG/5 ML SOLN N/APROPRANOLOL 40 MG TABLET N/APROPRANOLOL 40 MG/5 ML SOLN N/APROPRANOLOL 60 MG TABLET N/APROPRANOLOL 80 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PROPRANOLOL ER 120 MG CAPSULE N/APROPRANOLOL ER 160 MG CAPSULE N/APROPRANOLOL ER 60 MG CAPSULE N/APROPRANOLOL ER 80 MG CAPSULE N/APROPRANOLOL HCL POWDER N/APROPRANOLOL-HCTZ 40-25 MG TAB N/APROPRANOLOL-HCTZ 80-25 MG TAB N/APROPYLTHIOURACIL 50 MG TABLET N/APRORENAL MULTIVITAMIN TABLET N/APROSIGHT TABLET N/APROVIL 200 MG TABLET N/APSYLLIUM FIBER 0.52 G CAPSULE N/APSYLLIUM SEED POWDER N/APUB 28G LANCETS N/APUB ADVANCED LANCING DEVICE N/APUB ALLERGY 12.5 MG/5 ML LIQ N/APUB ALLERGY 25 MG CAPSULE N/APUB ALLERGY 25 MG TABLET N/APUB ALLERGY RELIEF 10 MG TAB N/APUB ALLERGY RELIEF 180 MG TAB N/APUB ALLERGY RELIEF D-24HR TAB N/APUB ALLERGY RELIEF-D TABLET N/APUB ANTACID 500 MG CHEW TABLET N/APUB ARTHRITIS PAIN ER 650 MG N/APUB ASPIRIN 325 MG TABLET N/APUB ATHLETIC FOOT 1% CREAM N/APUB CALCIUM ANTACID 750 MG N/APUB CALCIUM CARB 1;000 MG TAB N/APUB CHILDREN'S ALLERGY 1 MG/ML N/APUB CHILDREN'S PROFEN IB SUSP N/APUB CHILDREN'S PROFENIB SUSP N/APUB DOCUSATE SODIUM 100 MG CAP N/APUB FAMOTIDINE 20 MG TABLET N/A

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PUB FIBER CAPSULE N/APUB GLUCOSE 4 GRAM TABLET CHEW N/APUB HYDROCREAM 1% N/APUB IBUPROFEN 200 MG TABLET N/APUB INFANTS' GAS RELIEF DROPS N/APUB INS SYRIN 0.3 ML 30GX1/2'' N/APUB INS SYRINGE 1 ML 30GX1/2'' N/APUB INSUL SYR 0.3 ML 31GX5/16'' N/APUB INSUL SYR 0.5 ML 30GX1/2'' N/APUB INSUL SYR 0.5 ML 31GX5/16'' N/APUB INSULIN SYR 1 ML 31GX5/16'' N/APUB MICONAZOLE3DAY COMBO PACK N/APUB MULTIVITAMIN 50 PLUS TAB N/APUB NO DRIP 0.05% NASAL SPRAY N/APUB OMEPRAZOLE DR 20 MG TABLET N/APUB ORIGINAL NASAL SPRAY 0.05% N/APUB OXYMETAZOLINE HCL 0.05% N/APUB PAIN RELIEF 500 MG CAPLET N/APUB PAIN RELIEF 500 MG GELTAB N/APUB PAIN RELIEF 500 MG TABLET N/APUB PINK BISMUTH MAX STR LIQ N/APUB STOMACH RLF 262 MG/15 ML N/APUB TRIPLE ANTIBIOTIC OINTMENT N/APUB TUSSIN 100 MG/5 ML SYRUP N/APUB TUSSIN CF COUGH-COLD LIQ N/APUB TUSSIN DM LIQUID N/APUB UNIFINE PNTP PLUS 31GX3/16 N/APUMPKIN FLAVOR LIQUID N/APURIFIED WATER N/APV AUTOLET LANCING DEVICE N/APV UNIFINE PENTIP PLUS 31GX8MM N/APV UNILET MICRO THIN 33G LANCT N/APV UNILET SUPER THIN 30G LANCT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

PYRAZINAMIDE 500 MG TABLET N/APYRIDOSTIGMINE BR 60 MG TABLET N/APYRIDOXINE 25 MG TABLET N/APYRIDOXINE 250 MG TABLET N/APYRIDOXINE 50 MG TABLET N/APYRIDOXINE 500 MG TABLET N/APYRIMETHAMINE 25 MG TABLET N/APYRIMETHAMINE POWDER N/AQC 3 DAY VAGINAL 4% CREAM N/AQC ACETAMINOPHEN 8-HR 650 MG N/AQC ALCOHOL 70% SWABS N/AQC ALL DAY ALLERGY 10 MG TAB N/AQC ALLERGY RELIEF 50 MCG SPRAY N/AQC ANTACID 500 MG CHEW TABLET N/AQC ANTACID XTRA STR CHEW TAB N/AQC ANTI-DIARRHEAL 2 MG CAPLET N/AQC ANTI-DIARRHEAL 2 MG SOFTGEL N/AQC ARTHRITIS PAIN ER 650 MG N/AQC ASPIRIN 325 MG TABLET N/AQC ASPIRIN EC 325 MG TABLET N/AQC ASPIRIN EC 81 MG TABLET N/AQC CALCIUM 600 MG-VIT D TAB N/AQC CALCIUM 600-VIT D3 400 TAB N/AQC CASTOR OIL N/AQC CHILD ALLERGY 12.5 MG/5 ML N/AQC CHILD IBUPROFEN 100 MG/5 ML N/AQC CHLORPHENIRAMINE 4 MG TAB N/AQC COMPLETE ALLERGY 25 MG CAP N/AQC COMPLETE ALLERGY 25 MG CPLT N/AQC DIARRHEA RLF 262 MG/15 ML N/AQC FEXOFENADINE HCL 180 MG TAB N/AQC FIBER CAPSULE N/AQC FLUTICASONE PROP 50 MCG N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

QC IBUPROFEN 200 MG CAPLET N/AQC IBUPROFEN IB 200 MG CAPLET N/AQC IBUPROFEN IB 200 MG TABLET N/AQC JR. NON-ASPIRIN 160 MG TAB N/AQC LORATADINE 10 MG TABLET N/AQC LORATADINE-D 24HR TABLET N/AQC MAXIMUM DAILY MULTIVIT TAB N/AQC MEN'S DAILY MULTIVIT-MIN TB N/AQC MICONAZOLE-7 CREAM N/AQC MUCUS RELIEF ER 600 MG TAB N/AQC NATURAL VEG LAXATIVE TABLET N/AQC NATURA-LAX 17 GM POWDER N/AQC NON-ASPIRIN 500 MG CAPLET N/AQC NON-ASPIRIN 500 MG GELCAP N/AQC NON-ASPIRIN 500 MG TABLET N/AQC NON-ASPIRIN PAIN RELIEF TB N/AQC OMEPRAZOLE MAG DR 20.6 MG N/AQC PAIN RELIEF 325 MG TABLET N/AQC PAIN RELIEF 500 MG CAPLET N/AQC SENNA LAXATIVE 8.6 MG TAB N/AQC STOOL SOFTENER 100 MG SFTGL N/AQC SWEET OIL N/AQC TUSSIN CF LIQUID N/AQC TUSSIN DM LIQUID N/AQC TUSSIN MUCUS-CONG 200 MG/10 N/AQC UNIFINE PENTIPS 32GX5/32'' N/AQC UNILET SUPER THIN 30G LANCT N/AQC UNILET ULTRA THIN 28G LANCT N/AQUARTETTE TABLET N/AQUIN B STRONG WITH C & ZINC TB N/AQUINAPRIL 10 MG TABLET N/AQUINAPRIL 20 MG TABLET N/AQUINAPRIL 40 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

QUINAPRIL 5 MG TABLET N/AQUINAPRIL-HCTZ 10-12.5 MG TAB N/AQUINAPRIL-HCTZ 20-12.5 MG TAB N/AQUINAPRIL-HCTZ 20-25 MG TAB N/AQUINIDINE GLUC ER 324 MG TAB N/AQUINIDINE SULFATE 200 MG TAB N/AQUINIDINE SULFATE 300 MG TAB N/AQUINTABS-M IRON FREE TABLET N/AQUINTABS-M TABLET N/AQVAR REDIHALER 40 MCG N/AQVAR REDIHALER 80 MCG N/ARA 12HR NASAL SPRAY 0.05% N/ARA 8 HOUR PAIN RELIEF 650 MG N/ARA ACETAMINOPHEN 325 MG TABLET N/ARA ACETAMINOPHEN 500 MG CAPLET N/ARA ACETAMINOPHEN 500 MG GELCAP N/ARA ACETAMINOPHEN 500 MG TABLET N/ARA ACETAMINOPHEN ER 650 MG TAB N/ARA ACID REDUCER 20 MG TABLET N/ARA ALCOHOL SWABS N/ARA ALLERGY 25 MG TABLET N/ARA ALLERGY MED 25 MG TABLET N/ARA ALLERGY MED CAPSULE N/ARA ALLERGY RELIEF 10 MG TABLET N/ARA ALLERGY RELIEF 180 MG TAB N/ARA ALLERGY RELIEF 25 MG CAP N/ARA ALLERGY RELIEF 4 MG TABLET N/ARA ALLERGY-CONGESTION 12HR TAB N/ARA ANTACID 500 MG CHEWABLE TAB N/ARA ANTI-DIARRHEAL 2 MG CAPLET N/ARA ANTI-DIARRHEAL 2 MG SOFTGEL N/ARA ANTI-ITCH 1% CREAM N/ARA ANTI-ITCH 1% OINTMENT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RA ANTI-TUSSIVE DM SYRUP N/ARA ARTHRITIS PAIN ER 650 MG N/ARA ASPIRIN 325 MG TABLET N/ARA ASPIRIN EC 325 MG TABLET N/ARA ASPIRIN EC 81 MG TABLET N/ARA ATHENOL 325 MG TABLET N/ARA BUDESONIDE 32 MCG SPRAY N/ARA CALCIUM 600 MG TABLET N/ARA CALCIUM 600-MINERALS TAB N/ARA CALCIUM 600-VIT D3 400 TAB N/ARA CALCIUM CITRATE - VIT D TAB N/ARA CALCIUM CITRATE-VIT D3 TAB N/ARA CENTRAL-VITE WOMEN'S TABLET N/ARA CETIRI-D ER TABLET N/ARA CETIRIZINE HCL 10 MG TABLET N/ARA CHILD ALLERGY 12.5 MG/5 ML N/ARA CHILD ALLERGY RELF 1 MG/ML N/ARA CHILD IBUPROFEN 100 MG/5 ML N/ARA CHLORPHENIRAMINE 4 MG TAB N/ARA CLOTRIMAZOLE 1% TOP CREAM N/ARA CLOTRIMAZOLE 1% VAG CREAM N/ARA COL-RITE 100 MG CAPSULE N/ARA COL-RITE 100 MG SOFTGEL N/ARA COMPLETE ALLERGY 25 MG CPLT N/ARA COUGH-COLD MUCUS RLF CF LIQ N/ARA DIPHEDRYL 12.5 MG/5 ML ELIX N/ARA DIPHEDRYL 12.5 MG/5 ML LIQ N/ARA EXPECTORANT COUGH SYRUP N/ARA EYE ITCH RELIEF 0.025% DROP N/ARA E-ZJECT 26G LANCETS N/ARA E-ZJECT 28G LANCETS N/ARA E-ZJECT 30G LANCETS N/ARA E-ZJECT COLOR 33G LANCETS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RA FIBER CAPSULE N/ARA FIBER THERAPY CAPSULE N/ARA FISH OIL 1;000 MG SOFTGEL N/ARA FISH OIL 120-180 SOFTGEL N/ARA FOLIC ACID 0.4 MG TABLET N/ARA FOLIC ACID 800 MCG TABLET N/ARA GLUCOSE 4 GRAM TABLET CHEW N/ARA HEALTH CARE LANCING DEVICE N/ARA HYDROCORTISONE 1% CREAM N/ARA IBUPROFEN 100 MG/5 ML SUSP N/ARA IBUPROFEN 200 MG CAPLET N/ARA IBUPROFEN 200 MG TABLET N/ARA INS SYR 0.5 ML 29GX1/2'' N/ARA INS SYR 0.5 ML 30GX5/16'' N/ARA INS SYR 1 ML 29GX1/2'' N/ARA INS SYRINGE 1 ML 30GX5/16'' N/ARA IRON 65 MG TABLET N/ARA JOCK ITCH CREAM N/ARA LANSOPRAZOLE DR 15 MG CAP N/ARA LAXATIVE PEG 3350 POWDER N/ARA LICE PYRINYL SHAMPOO N/ARA LICE TREATMENT 1% CRM RINSE N/ARA LORATA-D 24-HOUR TABLET N/ARA LORATADINE 10 MG TABLET N/ARA LUBRICANT 0.5% EYE DROP N/ARA MEN'S ONE DAILY TABLET N/ARA MICONAZOLE 3 COMBO PACK N/ARA MICONAZOLE 3 KIT N/ARA MICONAZOLE 7 CREAM N/ARA MOTION SICKNESS RLF TB CHEW N/ARA NASAL ALLERGY 24HR SPRAY N/ARA NASAL SPRAY N/ARA NASAL SPRAY 0.05% N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RA NIACIN 100 MG TABLET N/ARA NIACIN 500 MG TABLET N/ARA NON-ASPIRIN 500 MG CAPLET N/ARA OMEPRAZOLE DR 20 MG TABLET N/ARA ONE DAILY ENERGY TABLET N/ARA ONE DAILY MAXIMUM TABLET N/ARA ONE DAILY WOMEN'S TABLET N/ARA PEN NEEDLE 31GX3/16'' N/ARA PEN NEEDLE 31GX5/16'' N/ARA PETROLEUM JELLY N/ARA PINK BISMUTH 262 MG/15 ML N/ARA SENNA 8.6 MG TABLET N/ARA SENNA-LAX 8.6 MG TABLET N/ARA SLEEP AID 25 MG TABLET N/ARA STOMACH RELIEF 262 MG/15 ML N/ARA STOMACH RELIEF MAX STR LIQ N/ARA STOOL SOFTENER 100 MG CAP N/ARA TRIPLE ANTIBIOTIC OINTMENT N/ARA TUSSIN CHEST CONGESTION SYR N/ARA TUSSIN COUGH LIQUID N/ARA TUSSIN DM COUGH-CHEST SYRUP N/ARA TUSSIN DM SYRUP N/ARA VITAMIN B-6 100 MG TABLET N/ARA VITAMIN B-6 50 MG TABLET N/ARA VITAMIN D3 1;000 UNIT TAB N/ARA VITAMIN D3 2;000 UNIT SFGL N/ARA VITAMIN D3 2;000 UNIT SFTGL N/ARA VITAMIN D3 5;000 UNIT SFTGL N/ARA WART REMOVER 17% LIQUID N/ARABEPRAZOLE SOD DR 20 MG TAB N/ARALOXIFENE HCL 60 MG TABLET N/ARAMIPRIL 1.25 MG CAPSULE N/ARAMIPRIL 10 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RAMIPRIL 2.5 MG CAPSULE N/ARAMIPRIL 5 MG CAPSULE N/ARANEXA ER 1;000 MG TABLET N/ARANEXA ER 500 MG TABLET N/ARANOLAZINE ER 1;000 MG TABLET N/ARANOLAZINE ER 500 MG TABLET N/ARASPBERRY CONC FLAVOR LIQUID N/ARASPBERRY CONCENTRATE FLAVOR N/ARASPBERRY FLAVOR N/ARASPBERRY FLAVOR CONCENTRATE N/ARASPBERRY FLAVOR LIQUID N/ARASPBERRY FLAVOR POWDER N/ARASPBERRY FLAVOR SOLUTION N/ARASPBERRY SYRUP N/AREBIF 22 MCG/0.5 ML SYRINGE N/AREBIF 44 MCG/0.5 ML SYRINGE N/AREBIF REBIDOSE 22 MCG/0.5 ML N/AREBIF REBIDOSE 44 MCG/0.5 ML N/AREBIF REBIDOSE TITRATION PACK N/AREBIF TITRATION PACK N/ARECLIPSEN 28 DAY TABLET N/ARECOMBIVAX HB 10 MCG/ML SYR N/ARECOMBIVAX HB 40 MCG/ML VIAL N/ARECOMBIVAX HB 5 MCG/0.5 ML SYR N/ARECTIV 0.4% OINTMENT N/AREESE'S PINWORM 144 MG/ML SUSP N/AREFRESH CELLUVISC 1% EYE DROPS N/AREFRESH LIQUIGEL 1% EYE DROP N/ARELENZA 5 MG DISKHALER N/ARELI ON 31G X 1/4'' NEEDLES N/ARELIAMED 28G LANCETS N/ARELIAMED 30G LANCETS N/ARELIAMED LANCING DEVICE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RELIAMED MINI LANCING DEVICE N/ARELIAMED SAFETY SEAL 28G LANCT N/ARELIAMED SAFETY SEAL 30G LANCT N/ARELION ALCOHOL 70% SWABS N/ARELION GLUCOSE 4 GRAM TAB CHEW N/ARELI-ON GLUCOSE 4 GRAM TAB CHW N/ARELION INS SYR 0.3 ML 29GX1/2'' N/ARELION INS SYR 0.3 ML 30GX5/16 N/ARELION INS SYR 0.5 ML 29GX1/2'' N/ARELION INS SYR 1 ML 29GX1/2'' N/ARELION INS SYR 1 ML 30GX5/16'' N/ARELION INS SYR 1 ML 31GX5/16'' N/ARELION INSULIN SYR 0.5 ML N/ARELION KETONE TEST STRIP N/ARELION LANCING DEVICE N/ARELION MICRO THIN 33G LANCET N/ARELION NOVOLIN 70-30 VIAL N/ARELION NOVOLIN N 100 UNIT/ML N/ARELION NOVOLIN R 100 UNIT/ML N/ARELION SYR 0.5 ML 30GX5/16'' N/ARELION SYRING 0.3 ML 31GX5/16'' N/ARELION SYRING 0.5 ML 31GX5/16'' N/ARELION THIN 26G LANCETS N/ARELION ULTRA THIN 30G LANCETS N/ARELION ULTRA THIN PLUS 33G N/ARELION ULTRA THIN PLUS LANCETS N/AREMEDY ANTIFUNGAL 2% CREAM N/AREMODULIN 1 MG/ML VIAL N/AREMODULIN 10 MG/ML VIAL N/AREMODULIN 2.5 MG/ML VIAL N/AREMODULIN 5 MG/ML VIAL N/ARENAGEL 800 MG TABLET N/ARENFLEXIS 100 MG VIAL N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RENVELA 0.8 GM POWDER PACKET N/ARENVELA 2.4 GM POWDER PACKET N/ARENVELA 800 MG TABLET N/AREPAGLINIDE 0.5 MG TABLET N/AREPAGLINIDE 1 MG TABLET N/AREPAGLINIDE 2 MG TABLET N/AREPAGLINIDE-METFORMIN 1-500 MG N/AREPAGLINIDE-METFORMIN 2-500 MG N/AREPLESTA 50;000 UNITS WAFER N/ARESERPINE POWDER N/ARETINOIC ACID POWDER N/ARETROVIR 10 MG/ML SYRUP N/ARETROVIR 100 MG CAPSULE N/ARETROVIR 200 MG/20 ML VIAL N/AREVLIMID 10 MG CAPSULE N/AREVLIMID 15 MG CAPSULE N/AREVLIMID 2.5 MG CAPSULE N/AREVLIMID 25 MG CAPSULE N/AREVLIMID 5 MG CAPSULE N/AREXALL UNIVERSAL 1 30G LANCETS N/AREYATAZ 150 MG CAPSULE N/AREYATAZ 200 MG CAPSULE N/AREYATAZ 300 MG CAPSULE N/AREYATAZ 50 MG POWDER PACKET N/ARHINOCORT ALLERGY 32 MCG SPRAY N/ARHOGAM ULTRA-FILTERED PLUS SYR N/ARHOPHYLAC 300 MCG/2 ML SYRINGE N/ARIBAVIRIN 200 MG CAPSULE N/ARIBAVIRIN 200 MG TABLET N/ARID ESSENTIAL LICE KIT N/ARID LICE KILLING SHAMPOO N/ARIDAURA 3 MG CAPSULE N/ARIFAMPIN 150 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

RIFAMPIN 300 MG CAPSULE N/ARIFAMPIN POWDER N/ARIGHTEST GD500 LANCING DEVICE N/ARIGHTEST GL300 30G LANCETS N/ARIMANTADINE HCL 100 MG TABLET N/ARITEFLO SPACER N/ARITONAVIR 100 MG TABLET N/ARIVASTIGMINE 1.5 MG CAPSULE N/ARIVASTIGMINE 13.3 MG/24HR PTCH N/ARIVASTIGMINE 3 MG CAPSULE N/ARIVASTIGMINE 4.5 MG CAPSULE N/ARIVASTIGMINE 4.6 MG/24HR PATCH N/ARIVASTIGMINE 6 MG CAPSULE N/ARIVASTIGMINE 9.5 MG/24HR PATCH N/ARIZATRIPTAN 10 MG TABLET N/ARIZATRIPTAN 5 MG TABLET N/AROBAFEN 200 MG/10 ML SYRUP N/AROBAFEN DM CGH-CHEST CONG SYRP N/AROBAFEN DM COUGH LIQUID N/AROBAFEN DM COUGH SYRUP N/AROBATHOL BATH OIL N/AROBITUSSIN COUGH-COLD CF LIQ N/AROOT BEER FLAVOR LIQUID N/AROPINIROLE HCL 0.25 MG TABLET N/AROPINIROLE HCL 0.5 MG TABLET N/AROPINIROLE HCL 1 MG TABLET N/AROPINIROLE HCL 2 MG TABLET N/AROPINIROLE HCL 3 MG TABLET N/AROPINIROLE HCL 4 MG TABLET N/AROPINIROLE HCL 5 MG TABLET N/AROSADAN 0.75% CREAM N/AROSADAN 0.75% GEL N/ASAFESNAP INSUL SYRINGE 0.3 ML N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SAFESNAP INSUL SYRINGE 0.5 ML N/ASAFESNAP INSULIN SYRINGE 1 ML N/ASAFETUSSIN DM LIQUID N/ASAFETY 21G LANCETS N/ASAFETY 28G LANCETS N/ASAFETY LANCETS 26G N/ASAFETY SEAL 28G LANCETS N/ASAFETY SEAL 30G LANCETS N/ASAFETY-LET 30G LANCETS N/ASAFYRAL TABLET N/ASALICYLIC ACID 26% LIQUID N/ASALICYLIC ACID 27.5% LIQUID N/ASALICYLIC ACID POWDER N/ASALSALATE 500 MG TABLET N/ASALSALATE 750 MG TABLET N/ASANDOSTATIN 0.05 MG/ML AMPUL N/ASANDOSTATIN 0.1 MG/ML AMPUL N/ASANDOSTATIN 0.5 MG/ML AMPUL N/ASANDOSTATIN LAR DEPOT 10 MG KT N/ASANDOSTATIN LAR DEPOT 20 MG KT N/ASANDOSTATIN LAR DEPOT 30 MG KT N/ASANTYL OINTMENT N/ASAPS ALCOHOL 70% PREP PADS N/ASAPS TWIST TOP 30G LANCET N/ASAPS TWIST TOP 30G LANCETS N/ASARNA SENSITIVE 1% LOTION N/ASASSAFRAS OIL N/ASAVELLA 100 MG TABLET N/ASAVELLA 12.5 MG TABLET N/ASAVELLA 25 MG TABLET N/ASAVELLA 50 MG TABLET N/ASAVELLA TITRATION PACK N/ASAVISION TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SB EX-STRENGTH NON-ASPIRIN TAB N/ASB LICE KILLING SHAMPOO N/ASCOT-TUSSIN 100 MG/5 ML LIQ N/ASEA-OMEGA 1;000 MG SOFTGEL N/ASECURA ANTIFUNGAL 2% CREAM N/ASEGLUROMET 2.5-1;000 MG TABLET N/ASEGLUROMET 2.5-500 MG TABLET N/ASEGLUROMET 7.5-1;000 MG TABLET N/ASEGLUROMET 7.5-500 MG TABLET N/ASELECT-OB + DHA PACK N/ASELEGILINE HCL 5 MG CAPSULE N/ASELEGILINE HCL 5 MG TABLET N/ASELEGILINE HCL POWDER N/ASELENIUM SULFIDE 2.25% SHAMPOO N/ASELENIUM SULFIDE 2.5% LOTION N/ASELZENTRY 150 MG TABLET N/ASELZENTRY 20 MG/ML ORAL SOLN N/ASELZENTRY 25 MG TABLET N/ASELZENTRY 300 MG TABLET N/ASELZENTRY 75 MG TABLET N/ASENIOR TABS N/ASENNA 8.6 MG TABLET N/ASENNA 8.8 MG/5 ML LIQUID N/ASENNA 8.8 MG/5 ML SYRUP N/ASENNA 8.8 MG/5 ML SYRUP GRX N/ASENNA LAX 8.6 MG TABLET N/ASENNA LAXATIVE 8.6 MG TABLET N/ASENNA SYRUP N/ASENNA-LAX 8.6 MG TABLET N/ASENNA-TIME 8.6 MG TABLET N/ASENNO TABLET N/ASENTRY SENIOR MULTIVITAMIN TAB N/ASENTRY SENIOR TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SENTRY TABLET N/ASESAME OIL N/ASEVELAMER 0.8 GM POWDER PACKET N/ASEVELAMER 2.4 GM POWDER PACKET N/ASEVELAMER CARBONATE 800 MG TAB N/ASF 1.1% GEL N/ASF 5000 PLUS CREAM N/ASHAKE THAT ACHE 500 MG CAPLET N/ASHAROBEL 0.35 MG TABLET N/ASHINGRIX VIAL KIT N/ASHOPKO AUTOLET LANCING DEVICE N/ASHOPKO ON-THE-GO 30G LANCETS N/ASHOPKO UNIFINE PENTIPS 4MM 32G N/ASHOPKO UNIFINE PENTIPS 5MM 31G N/ASHOPKO UNIFINE PENTIPS 8MM 31G N/ASHOPKO UNIFINE PNTIPS 12MM 29G N/ASHOPKO UNILET SUPER THIN 30G N/ASHOPKO UNILET ULTRA THIN 28G N/ASIDEROL TABLET N/ASILADRYL 12.5 MG/5 ML LIQUID N/ASILDENAFIL 10 MG/ML ORAL SUSP N/ASILDENAFIL 20 MG TABLET N/ASILTUSSIN DM COUGH SYRUP N/ASILTUSSIN DM DAS LIQUID N/ASILTUSSIN SA 100 MG/5 ML SYR N/ASILVER SULFADIAZINE 1% CREAM N/ASIMETHICONE 40 MG/0.6 ML DROP N/ASIMETHICONE 80 MG TAB CHEW N/ASIMILAC STERILIZED WATER N/ASIMPLE DIAGNSTIC LANCET DEVICE N/ASIMPLE SYRUP N/ASIMVASTATIN 10 MG TABLET N/ASIMVASTATIN 20 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SIMVASTATIN 40 MG TABLET N/ASIMVASTATIN 5 MG TABLET N/ASIMVASTATIN 80 MG TABLET N/ASINGLE-LET LANCETS N/ASINUS RELIEF 0.05% NASAL SPRAY N/ASINUS RELIEF NASAL SPRAY 0.05% N/ASIROLIMUS 0.5 MG TABLET N/ASIROLIMUS 1 MG TABLET N/ASIROLIMUS 2 MG TABLET N/ASKYLA 13.5 MG SYSTEM N/ASLEEP TABS 25 MG TABLET N/ASLO-NIACIN 250 MG TABLET N/ASM 12HR NASAL SPRAY 0.05% N/ASM 8 HOUR PAIN RELIEF 650 MG N/ASM ACID REDUCER 20 MG TABLET N/ASM ACID REDUCER 200 MG TABLET N/ASM ALCOHOL 70% PREP PADS N/ASM ALCOHOL PREP PADS N/ASM ALL DAY ALLERGY 1 MG/ML SYR N/ASM ALL DAY ALLERGY 10 MG TAB N/ASM ALL DAY ALLERGY-D TABLET N/ASM ALLERGY 4 MG TABLET N/ASM ALLERGY 4-HR 4 MG TABLET N/ASM ALLERGY RELIEF 10 MG ODT N/ASM ALLERGY RELIEF 12.5 MG/5 ML N/ASM ALLERGY RELIEF 25 MG CAP N/ASM ALLERGY RELIEF 25 MG TABLET N/ASM ALLERGY RELIEF 50 MCG SPRAY N/ASM ANTACID 500 MG CHEW TABLET N/ASM ANTACID XTRA STR CHEW TAB N/ASM ANTI-DANDRUFF 0.5% SHAMPOO N/ASM ANTI-DIARRHEAL 2 MG CAPLET N/ASM ANTI-DIARRHEAL 2 MG SOFTGEL N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SM ANTIFUNGAL 1% TOPICAL CREAM N/ASM ANTIOXIDANT VITAMINS TABLET N/ASM ARTHRIT PAIN RLF ER 650 MG N/ASM ARTHRITIS PAIN ER 650 MG N/ASM ARTHRITIS PAIN RELF ER 650 N/ASM ASPIRIN 325 MG TABLET N/ASM ASPIRIN EC 325 MG TABLET N/ASM ASPIRIN EC 81 MG TABLET N/ASM ATHLETE'S 1% FOOT CREAM N/ASM B COMPLEX WITH VIT C TABLET N/ASM CAL ANTACID 500 MG CHEW TAB N/ASM CAL ANTACID 750 MG CHEW TAB N/ASM CAL CIT 315 MG-D3 250 UNIT N/ASM CALCIUM 600 MG TABLET N/ASM CALCIUM 600-VIT D3 400 TAB N/ASM CALCIUM 600-VIT D3 800 TAB N/ASM CALCIUM ANTACID TAB CHEW N/ASM CASTOR OIL N/ASM CHILD ALL DAY ALLER 1 MG/ML N/ASM CHILD ALLERGY 12.5 MG/5 ML N/ASM CHILD LORATADINE 5 MG/5 ML N/ASM CHILD MUCUS RELIEF M-S COLD N/ASM CLEARLAX POWDER N/ASM CLOTRIMAZOLE 1% TOP CREAM N/ASM CLOTRIMAZOLE 1% VAG CREAM N/ASM COMPLETE 50 PLUS TABLET N/ASM COMPLETE ADVANCED TABLET N/ASM COMPLETE MULTI-VIT-MINERAL N/ASM COMPLETE PREMIUM VITAMIN TB N/ASM COMPLETE SENIOR FORMULA TAB N/ASM EYE ITCH RELIEF 0.025% DROP N/ASM FEXOFENADINE HCL 180 MG TAB N/ASM FEXOFENADINE HCL 60 MG TAB N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SM FIBER SMOOTH POWDER N/ASM FIBER SMOOTH TEXTURE PWD N/ASM FISH OIL 1;000 MG SOFTGEL N/ASM FISH OIL 1;200 MG SOFTGEL N/ASM FISH OIL 554 MG SOFTGEL N/ASM FISH OIL CONCENTRATE SFG N/ASM FOLIC ACID 0.4 MG TABLET N/ASM FOLIC ACID 400 MCG TABLET N/ASM GAS RELIEF 80 MG TAB CHEW N/ASM GLUCOSE 4 GRAM TAB CHEW N/ASM GLYCERIN 99.5% LIQUID N/ASM HAIR; SKIN AND NAILS CAPLET N/ASM HYDROCORTISONE 0.5% CREAM N/ASM HYDROCORTISONE 0.5% OINTMNT N/ASM HYDROCORTISONE 1% CREAM N/ASM HYDROCORTISONE 1% OINTMENT N/ASM HYDROCORTISONE PLUS 1% CRM N/ASM HYDROCORTISONE-ALOE 1% CRM N/ASM IBUPROFEN 100 MG/5 ML SUSP N/ASM IBUPROFEN 200 MG CAPLET N/ASM IBUPROFEN 200 MG TABLET N/ASM IBUPROFEN IB 200 MG CAPLET N/ASM IBUPROFEN IB 200 MG TABLET N/ASM INF GAS RELIEF 20 MG/0.3 ML N/ASM INS SYR 0.5 ML 29GX1/2'' N/ASM INS SYR 0.5 ML 30GX5/16'' N/ASM INS SYR 1 ML 29GX1/2'' N/ASM INS SYRING 0.3 ML 30GX5/16'' N/ASM INS SYRINGE 1 ML 28GX1/2'' N/ASM INS SYRINGE 1 ML 30GX5/16'' N/ASM INSUL SYR 0.3 ML 31GX5/16'' N/ASM INSUL SYR 0.5 ML 31GX5/16'' N/ASM INSULIN SYR 0.3 ML 29GX1/2'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SM INSULIN SYR 0.5 ML 28GX1/2'' N/ASM INSULIN SYR 1 ML 31GX5/16'' N/ASM IRON 325 MG TABLET N/ASM IRON 65 MG TABLET N/ASM LANCETS 21G N/ASM LANSOPRAZOLE DR 15 MG CAP N/ASM LICE KILLING SHAMPOO N/ASM LICE TREATMENT 1% CRM RINSE N/ASM LICE TREATMENT PERMETHRIN N/ASM LORATADINE 10 MG ODT N/ASM LORATADINE 10 MG TABLET N/ASM LORATADINE 5 MG/5 ML SYRUP N/ASM LORATA-DINE D 24HR TABLET N/ASM LORATADINE-D 12 HOUR TABLET N/ASM LUBRICAT PLUS 0.5% EYE DRPS N/ASM MAX STRENGTH WART REMOVER N/ASM MEN'S ONE DAILY TABLET N/ASM MICONAZOLE 2% TOPICAL CREAM N/ASM MICONAZOLE 2% VAGINAL CREAM N/ASM MICONAZOLE 3 COMBO PACK N/ASM MICONAZOLE 7 100 MG VAG SUP N/ASM MICONAZOLE 7 CREAM N/ASM MICRO THIN 33G LANCETS N/ASM MOTION SICKNESS 25 MG TAB N/ASM MUCUS ER 600 MG TABLET N/ASM MUCUS RELIEF COUGH LIQUID N/ASM MUCUS RELIEF ER 600 MG TAB N/ASM MULTIVITAMIN W-IRON TAB N/ASM NASAL 0.05% SPRAY N/ASM NASAL SPRAY 0.05% N/ASM NASAL SPRAY SINUS N/ASM NIACIN TR 250 MG TABLET N/ASM OMEPRAZOLE DR 20 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SM OPTI-VITAMIN TABLET N/ASM PAIN RELIEF 500 MG GELCAP N/ASM PAIN RELIEVER 325 MG TABLET N/ASM PAIN RELIEVER 500 MG CAPLET N/ASM PAIN RELIEVER 500 MG GELCAP N/ASM PAIN RELIEVER 500 MG TABLET N/ASM PAIN RELIEVER ER 650 MG N/ASM PETROLEUM JELLY N/ASM SENNA LAXATIVE 8.6 MG TAB N/ASM SLEEP AID 25 MG TABLET N/ASM SMOOTH ANTACID TAB CHEW N/ASM STOMACH RELIEF 262 MG/15 ML N/ASM STOMACH RELIEF 525 MG/30 ML N/ASM STOMACH RELIEF LIQUID N/ASM STOMACH RELIEF MAX STR LIQ N/ASM STOOL SOFTENER 100 MG SFTGL N/ASM STOOL SOFTENER 100 MG TAB N/ASM SUPER B COMPLEX-C CAPLET N/ASM SUPER THIN 30G LANCETS N/ASM SUPER VITAMIN B COMPLEX TAB N/ASM THIN LANCETS 26G N/ASM TRIPLE ANTIBIOTIC OINTMENT N/ASM TUSSIN 100 MG/5 ML LIQUID N/ASM TUSSIN CF SYRUP N/ASM TUSSIN DM LIQUID N/ASM TUSSIN DM SYRUP N/ASM TUSSIN MUCUS-CONG 200 MG/10 N/ASM ULTIMATE MEN'S COMPLETE TAB N/ASM ULTIMATE WOMEN'S 50+ TABLET N/ASM VITAMIN B-6 100 MG TABLET N/ASM VITAMIN D3 1;000 UNIT TAB N/ASM VITAMIN D3 2;000 UNIT SFTGL N/ASM WOMEN'S ONE DAILY TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SMART SENSE COLOR 33G LANCETS N/ASMART SENSE GLUCOSE 4 GRAM TAB N/ASMART SENSE STANDARD 21G N/ASMART SENSE SUPER THIN 30G N/ASMART SENSE THIN 26G LANCETS N/ASMARTEST LANCET N/ASMOOTHLAX POWDER N/ASMOOTHLAX POWDER PACKET N/ASOD POLYSTYREN SULF 15 G/60 ML N/ASODIUM BICARB 4.2% ABBJCT N/ASODIUM BICARB 7.5% ABBOJECT N/ASODIUM BICARB 8.4% ABBOJECT N/ASODIUM BICARB 8.4% SYRINGE N/ASODIUM BICARBONATE 4.2% VIAL N/ASODIUM BICARBONATE 8.4% VIAL N/ASODIUM BICARBONATE POWDER N/ASODIUM CHLORIDE 0.9% INHAL VL N/ASODIUM FLUORIDE 0.25 (0.55) MG N/ASODIUM FLUORIDE 0.5 MG(1.1 MG) N/ASODIUM FLUORIDE 0.5 MG/ML DROP N/ASODIUM FLUORIDE 1 MG (2.2 MG) N/ASODIUM POLYSTYRENE SULF POWDER N/ASODIUM SULFACETAMIDE 10% LOTN N/ASODIUM SULFACETAMIDE 10% WASH N/ASOF-LAX 100 MG GELCAP N/ASOFT TOUCH LANCETS N/ASOLIRIS 300 MG/30 ML VIAL N/ASOLO TABLET N/ASOLUS V2 28G LANCETS N/ASOLUS V2 30G TWIST LANCETS N/ASOLUS V2 LANCING DEVICE N/ASOMATULINE DEPOT 120 MG/0.5 ML N/ASOMATULINE DEPOT 60 MG/0.2 ML N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SOMATULINE DEPOT 90 MG/0.3 ML N/ASOOTHE 262 MG/15 ML SUSPENSION N/ASOOTHE 525 MG/30 ML SUSPENSION N/ASOOTHE REGULAR STRENGTH SUSP N/ASOOTHE SUSPENSION N/ASORBITOL 70% SOLUTION N/ASORBUGEN NR 150-15 MG/7.5 ML N/ASOTALOL 120 MG TABLET N/ASOTALOL 160 MG TABLET N/ASOTALOL 240 MG TABLET N/ASOTALOL 80 MG TABLET N/ASOTALOL AF 120 MG TABLET N/ASOTALOL AF 160 MG TABLET N/ASOTALOL AF 80 MG TABLET N/ASOVALDI 400 MG TABLET N/ASPEARMINT OIL N/ASPIRIVA 18 MCG CP-HANDIHALER N/ASPIRIVA RESPIMAT 1.25 MCG INH N/ASPIRIVA RESPIMAT 2.5 MCG INH N/ASPIRONOLACTONE 100 MG TABLET N/ASPIRONOLACTONE 25 MG TABLET N/ASPIRONOLACTONE 50 MG TABLET N/ASPIRONOLACTONE-HCTZ 25-25 TAB N/ASPORANOX 10 MG/ML SOLUTION N/ASPRINTEC 28 DAY TABLET N/ASPS 15 GM/60 ML SUSPENSION N/ASRONYX 0.10-0.02 MG TABLET N/ASSD 1% CREAM N/ASTAVUDINE 15 MG CAPSULE N/ASTAVUDINE 20 MG CAPSULE N/ASTAVUDINE 30 MG CAPSULE N/ASTAVUDINE 40 MG CAPSULE N/ASTEGLATRO 15 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

STEGLATRO 5 MG TABLET N/ASTERILANCE TL TWIST 30G LANCET N/ASTERILANCE TL TWIST 32G LANCET N/ASTERILE WATER FOR INJECTION N/ASTERILE WATER FOR IRRIGATION N/ASTEVIA 90% POWDER N/ASTEVIA EXTRACT POWDER N/ASTEVIA POWDER N/ASTIOLTO RESPIMAT INHAL SPRAY N/ASTIVARGA 40 MG TABLET N/ASTOMACH RELIEF 262 MG/15 ML N/ASTOMACH RELIEF 525 MG/15 ML N/ASTOMACH RELIEF MAX STR LIQUID N/ASTOMACH RLF 262 MG/15 ML SUSP N/ASTOMACH RLF 525 MG/30 ML SUSP N/ASTOOL SOFTENER 100 MG CAPSULE N/ASTOOL SOFTENER 100 MG SOFTGEL N/ASTOOL SOFTENER 100 MG TABLET N/ASTRAWBERRY CONCENTRATE FLAVOR N/ASTRAWBERRY CREAM FLAVOR LIQUID N/ASTRAWBERRY FLAVOR N/ASTRAWBERRY FLAVOR CONCENTRATE N/ASTRAWBERRY FLAVOR LIQUID N/ASTRAWBERRY FLAVOR OIL N/ASTRESS FORMULA TABLET N/ASTRESS FORMULA WITH IRON TAB N/ASTRESS FORMULA WITH ZINC TAB N/ASTRESS-C TABLET N/ASTRESS-C WITH IRON TABLET N/ASTRESS-C WITH ZINC TABLET N/ASTRESSTABS W/ZINC TABLET N/ASTRIBILD TABLET N/ASTRIVERDI RESPIMAT INHAL SPRAY N/A

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SUCRALFATE 1 GM TABLET N/ASUCRALFATE POWDER N/ASUDOGEST COLD AND ALLERGY TAB N/ASUDOGEST SINUS AND ALLERGY TAB N/ASULFACETAMIDE 10% EYE DROPS N/ASULFACETAMIDE 10% EYE OINTMENT N/ASULFACETAMIDE SOD 10% TOP SUSP N/ASULFADIAZINE 500 MG TABLET N/ASULFADIAZINE POWDER N/ASULFAMETHOXAZOLE-TMP DS TABLET N/ASULFAMETHOXAZOLE-TMP SS TABLET N/ASULFAMETHOXAZOLE-TMP SUSP N/ASULFASALAZINE 500 MG TABLET N/ASULFASALAZINE DR 500 MG TAB N/ASULFASALAZINE POWDER N/ASULFATRIM PEDIATRIC SUSPENSION N/ASULF-PRED 10-0.23% EYE DROPS N/ASULINDAC 150 MG TABLET N/ASULINDAC 200 MG TABLET N/ASULINDAC POWDER N/ASUMATRIPTAN 20 MG NASAL SPRAY N/ASUMATRIPTAN 4 MG/0.5 ML CART N/ASUMATRIPTAN 4 MG/0.5 ML INJECT N/ASUMATRIPTAN 5 MG NASAL SPRAY N/ASUMATRIPTAN 6 MG/0.5 ML INJECT N/ASUMATRIPTAN 6 MG/0.5 ML REFILL N/ASUMATRIPTAN 6 MG/0.5 ML SYRNG N/ASUMATRIPTAN 6 MG/0.5 ML VIAL N/ASUMATRIPTAN SUCC 100 MG TABLET N/ASUMATRIPTAN SUCC 25 MG TABLET N/ASUMATRIPTAN SUCC 50 MG TABLET N/ASUNVITE TABLET N/ASUPER ANTIOXIDANT CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SUPER ANTIOXIDANT SOFTGEL N/ASUPER B COMPLEX TABLET N/ASUPER CALCIUM 600-VIT D3 400 N/ASUPER DAILY D3 1;000 UNIT/DROP N/ASUPER DHA GEMS SOFTGEL N/ASUPER MULTIPLE-LOW IRON TABLET N/ASUPER OMEGA-3 SOFTGEL N/ASUPER SYNERSWEET FLAVOR POWDER N/ASUPER THERA VITE M TABLET N/ASUPER THIN 28G LANCETS N/ASUPER THIN 30G LANCETS N/ASUPRAX 100 MG TABLET CHEWABLE N/ASUPRAX 200 MG TABLET CHEWABLE N/ASUPRAX 400 MG CAPSULE N/ASUPRESS-DX PEDIATRIC DROPS N/ASURE COMFORT 0.3 ML SYRINGE N/ASURE COMFORT 0.5 ML SYRINGE N/ASURE COMFORT 1 ML SYRINGE N/ASURE COMFORT 28G LANCETS N/ASURE COMFORT 3/10 ML SYRINGE N/ASURE COMFORT 30G LANCETS N/ASURE COMFORT ALCOHOL PREP PADS N/ASURE COMFORT LANCING PEN N/ASURE-JECT INS 0.3 ML 31GX5/16'' N/ASURE-JECT INS 0.5 ML 31GX5/16'' N/ASURE-JECT INSU SYR U100 0.3 ML N/ASURE-JECT INSU SYR U100 0.5 ML N/ASURE-JECT INSU SYR U100 1 ML N/ASURE-JECT INSUL SYR U100 1 ML N/ASURE-JECT INSULIN SYRINGE 1 ML N/ASURE-LANCE 26G LANCETS N/ASURE-LANCE FLAT LANCETS N/ASURE-LANCE THIN 28G LANCETS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SURE-LANCE ULTRA THIN 30G N/ASURE-PEN LANCING DEVICE N/ASURE-PREP ALCOHOL PREP PADS N/ASURE-TOUCH LANCET N/ASUSPENSION VEHICLE NATURAL N/ASUSTIVA 200 MG CAPSULE N/ASUSTIVA 50 MG CAPSULE N/ASUSTIVA 600 MG TABLET N/ASV CALCIUM 600 MG TABLET N/ASV CALCIUM 600-VIT D3 400 TAB N/ASV CALCIUM 600-VIT D3 800 TAB N/ASV CALCIUM CITRATE-VIT D3 TAB N/ASV FISH OIL 1;000 MG SOFTGEL N/ASV FISH OIL EC 1;200 MG SOFTGL N/ASV FOLIC ACID 800 MCG TABLET N/ASV GELATIN 650 MG CAPSULE N/ASV HAIR; SKIN AND NAILS CAPLET N/ASV IRON 65 MG TABLET N/ASV L-CARNITINE 500 MG TABLET N/ASV SALMON OIL 1;000 MG SOFTGEL N/ASV VITAMIN B-6 100 MG TABLET N/ASV VITAMIN D3 1;000 UNIT GUMMY N/ASV VITAMIN D3 1;000 UNIT SFTGL N/ASV VITAMIN D3 2;000 UNIT SFTGL N/ASV VITAMIN D3 25MCG(1000 UNIT) N/ASV VITAMIN D3 400 UNIT SOFTGEL N/ASV VITAMIN D3 5;000 UNIT SFTGL N/ASW ALLERGY RELIEF 10 MG TAB N/ASW ALLERGY RELIEF-D TABLET N/ASW CLEARLAX POWDER N/ASW OMEPRAZOLE DR 20 MG TABLET N/ASWEET OIL N/ASWEETNESS ENHANCER FLAVOR LIQ N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

SWEET-SF SYRUP N/ASYEDA 28 TABLET N/ASYMAX-SL 0.125 MG TABLET SL N/ASYMFI 600-300-300 MG TABLET N/ASYMFI LO 400-300-300 MG TABLET N/ASYMTUZA 800-150-200-10 MG TAB N/ASYRPALTA SYRUP N/ASYRSPEND SF ALKA POWDER N/ASYRSPEND SF POWDER N/ASYRUP VEHICLE N/ATAB-A-VITE WITH IRON TABLET N/ATABLOID 40 MG TABLET N/ATACROLIMUS 0.03% OINTMENT N/ATACROLIMUS 0.1% OINTMENT N/ATACROLIMUS 0.5 MG CAPSULE N/ATACROLIMUS 1 MG CAPSULE N/ATACROLIMUS 5 MG CAPSULE N/ATACTINAL 325 MG TABLET N/ATACTINAL 500 MG CAPLET N/ATACTINAL 500 MG TABLET N/ATAKE ACTION 1.5 MG TABLET N/ATAME THE FLAME 500 MG CHEW TAB N/ATAMIFLU 6 MG/ML SUSPENSION N/ATAMOXIFEN 10 MG TABLET N/ATAMOXIFEN 20 MG TABLET N/ATAMSULOSIN HCL 0.4 MG CAPSULE N/ATANGERINE FLAVOR POWDER N/ATANGERINE SWEETENED FLAVOR PWD N/ATARINA FE 1-20 EQ TABLET N/ATARINA FE 1-20 TABLET N/ATAZTIA XT 120 MG CAPSULE N/ATAZTIA XT 180 MG CAPSULE N/ATAZTIA XT 240 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

TAZTIA XT 300 MG CAPSULE N/ATAZTIA XT 360 MG CAPSULE N/ATDVAX VIAL N/ATEABERRY OIL FLAVOR LIQUID N/ATECFIDERA DR 120 MG CAPSULE N/ATECFIDERA DR 240 MG CAPSULE N/ATECFIDERA STARTER PACK N/ATECHLITE 25G LANCETS N/ATECHLITE 28G LANCETS N/ATECHLITE 30G LANCETS N/ATELCARE ULTRA THIN 30G LANCETS N/ATEMIXYS 300-300 MG TABLET N/ATENCON 50-325 MG TABLET N/ATENOFOVIR DISOP FUM 300 MG TB N/ATERA-GEL TAR 0.5% SHAMPOO N/ATERAZOSIN 1 MG CAPSULE N/ATERAZOSIN 10 MG CAPSULE N/ATERAZOSIN 2 MG CAPSULE N/ATERAZOSIN 5 MG CAPSULE N/ATERBINAFINE 1% CREAM N/ATERBINAFINE HCL 250 MG TABLET N/ATERBUTALINE SULFATE 2.5 MG TAB N/ATERBUTALINE SULFATE 5 MG TAB N/ATERBUTALINE SULFATE POWDER N/ATERCONAZOLE 0.4% CREAM N/ATERCONAZOLE 0.8% CREAM N/ATERCONAZOLE 80 MG SUPPOSITORY N/ATERUMO INS SYR 0.3 ML 29GX1/2'' N/ATESTOSTERON CYP 1;000 MG/10 ML N/ATESTOSTERON CYP 2;000 MG/10 ML N/ATESTOSTERON ENAN 1;000 MG/5 ML N/ATESTOSTERONE 12.5 MG/1.25 GRAM N/ATESTOSTERONE 25 MG/2.5 GM PKT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

TESTOSTERONE 50 MG/5 GRAM PKT N/ATESTOSTERONE CYP 1;000 MG/5 ML N/ATESTOSTERONE CYP 100 MG/ML N/ATESTOSTERONE CYP 200 MG/ML N/ATESTOSTERONE CYP 500 MG/2.5 ML N/ATESTOSTERONE CYP 6;000 MG/30ML N/ATESTOSTERONE CYP MICRO POWDER N/ATESTOSTERONE ENAN 200 MG/ML N/ATESTOSTERONE MICRONIZED POWDER N/ATETRACYCLINE 250 MG CAPSULE N/ATETRACYCLINE 500 MG CAPSULE N/ATG 10PEH-380GFN-15DM TABLET N/ATHEOCHRON ER 100 MG TABLET N/ATHEOCHRON ER 200 MG TABLET N/ATHEOPHYLLINE 80 MG/15 ML SOLN N/ATHEOPHYLLINE ER 100 MG TABLET N/ATHEOPHYLLINE ER 200 MG TABLET N/ATHEOPHYLLINE ER 300 MG TAB N/ATHEOPHYLLINE ER 400 MG TABLET N/ATHEOPHYLLINE ER 450 MG TAB N/ATHEOPHYLLINE ER 600 MG TABLET N/ATHERA M PLUS TABLET N/ATHERA-D 2000 TABLET N/ATHERA-D RAPID REPLETION TABLET N/ATHERA-D SPORT 2;000 UNIT TAB N/ATHERA-GEL 0.5% SHAMPOO N/ATHERAGRAN-M PREMIER 50+ CAPLET N/ATHERA-M CAPLET N/ATHERA-M TABLET N/ATHERANATAL CORE NUTRITION TAB N/ATHERAPEUTIC MOISTURIZING CREAM N/ATHERAPEUTIC-M CAPLET N/ATHERAPEUTIC-M TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

THERA-TABS M CAPLET N/ATHERATRUM COMPLETE 50 PLUS TAB N/ATHERATRUM COMPLETE TABLET N/ATHEREMS-M TABLET N/ATHEROMEGA SOFTGEL N/ATHEROMEGA SPORT SOFTGEL N/ATHIN 26G LANCETS N/ATHIN LANCETS 28G N/ATHYROID POWDER N/ATIBSOVO 250 MG TABLET N/ATILIA FE 28 TABLET N/ATIMOLOL 0.25% GEL-SOLUTION N/ATIMOLOL 0.25% GFS GEL-SOLUTION N/ATIMOLOL 0.5% GEL-SOLUTION N/ATIMOLOL 0.5% GFS GEL-SOLUTION N/ATIMOLOL MALEATE 0.25% EYE DROP N/ATIMOLOL MALEATE 0.5% EYE DROPS N/ATIMOLOL MALEATE 10 MG TABLET N/ATIMOLOL MALEATE 20 MG TABLET N/ATIMOLOL MALEATE 5 MG TABLET N/ATIMOLOL MALEATE POWDER N/ATIMOPTIC 0.25% OCUDOSE DROP N/ATIMOPTIC 0.5% OCUDOSE DROP N/ATINEACIDE CREAM N/ATIVICAY 10 MG TABLET N/ATIVICAY 25 MG TABLET N/ATIVICAY 50 MG TABLET N/ATIZANIDINE HCL 2 MG TABLET N/ATIZANIDINE HCL 4 MG TABLET N/ATOBRADEX EYE OINTMENT N/ATOBRAMYCIN 0.3% EYE DROP N/ATOBRAMYCIN-DEXAMETH OPHTH SUSP N/ATOBREX 0.3% EYE OINTMENT N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

TODAY'S HLTH PN NEEDLE 6MM 31G N/ATOLMETIN SODIUM 200 MG TAB N/ATOLMETIN SODIUM 400 MG CAP N/ATOLMETIN SODIUM 600 MG TAB N/ATOLTERODINE TARTRATE 1 MG TAB N/ATOLTERODINE TARTRATE 2 MG TAB N/ATOPCARE ULTRA COMFORT SYRINGE N/ATOPCARE UNIVERSAL1 33G LANCETS N/ATOPCARE UNIVERSAL1 THIN LANCET N/ATORSEMIDE 10 MG TABLET N/ATORSEMIDE 100 MG TABLET N/ATORSEMIDE 20 MG TABLET N/ATORSEMIDE 5 MG TABLET N/ATOTAL ALLERGY 25 MG TABLET N/ATOTAL B WITH VIT C CAPLET N/ATOUJEO MAX SOLOSTR 300 UNIT/ML N/AT-PLUS 0.5% THERAPEUTIC SHMPOO N/ATRACLEER 125 MG TABLET N/ATRACLEER 62.5 MG TABLET N/ATRAMADOL HCL 50 MG TABLET N/ATRAMADOL-ACETAMINOPHN 37.5-325 N/ATRANDOLAPRIL 1 MG TABLET N/ATRANDOLAPRIL 2 MG TABLET N/ATRANDOLAPRIL 4 MG TABLET N/ATRAVATAN Z 0.004% EYE DROP N/ATRAVEL SICKNESS 25 MG TAB CHEW N/ATRAVOPROST 0.004% EYE DROP N/ATRELEGY ELLIPTA 100-62.5-25 N/ATRETINOIN 0.01% GEL N/ATRETINOIN 0.025% CREAM N/ATRETINOIN 0.025% GEL N/ATRETINOIN 0.05% CREAM N/ATRETINOIN 0.1% CREAM N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

TRETINOIN 10 MG CAPSULE N/ATRETINOIN ACID POWDER N/ATRIAMCINOLONE 0.025% CREAM N/ATRIAMCINOLONE 0.025% LOTION N/ATRIAMCINOLONE 0.025% OINT N/ATRIAMCINOLONE 0.1% CREAM N/ATRIAMCINOLONE 0.1% LOTION N/ATRIAMCINOLONE 0.1% OINTMENT N/ATRIAMCINOLONE 0.1% PASTE N/ATRIAMCINOLONE 0.5% CREAM N/ATRIAMCINOLONE 0.5% OINTMENT N/ATRIAMCINOLONE 55 MCG NASAL SPR N/ATRIAMCINOLONE ACETONIDE POWDER N/ATRIAMTERENE-HCTZ 37.5-25 MG CP N/ATRIAMTERENE-HCTZ 37.5-25 MG TB N/ATRIAMTERENE-HCTZ 75-50 MG TAB N/ATRIANEX 0.05% OINTMENT N/ATRICARE PRENATAL TABLET N/ATRI-ESTARYLLA TABLET N/ATRIFLURIDINE 1% EYE DROPS N/ATRI-LEGEST FE-28 DAY TABLET N/ATRI-LINYAH TABLET N/ATRI-LO-ESTARYLLA TABLET N/ATRI-LO-MARZIA TABLET N/ATRI-LO-SPRINTEC TABLET N/ATRILYTE WITH FLAVOR PACKETS N/ATRIMETHOBENZAMIDE 300 MG CAP N/ATRIMETHOPRIM 100 MG TABLET N/ATRIMETHOPRIM POWDER N/ATRINATE TABLET N/ATRI-PREVIFEM TABLET N/ATRI-SPRINTEC TABLET N/ATRIUMEQ 600-50-300 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

TRI-VITE-FLUORIDE 0.25 MG/ML N/ATRI-VITE-FLUORIDE 0.5 MG/ML N/ATRI-VIT-FLUOR 0.25 MG/ML DROP N/ATRI-VIT-FLUOR 0.5 MG/ML DROP N/ATRIVORA-28 TABLET N/ATRIZIVIR TABLET N/ATROCHE BASE N/ATROCHIBASE POWDER N/ATROCHIBASE S CLASSIC FLAKE N/ATROCHIBASE S FLAKES N/ATROGARZO 200 MG/1.33 ML VIAL N/ATROPICAL PUNCH FLAVOR LIQUID N/ATROPICAMIDE 0.5% EYE DROP N/ATROPICAMIDE 0.5% EYE DROPS N/ATROPICAMIDE 1% EYE DROP N/ATROPICAMIDE 1% EYE DROPS N/ATROPICAMIDE POWDER N/ATROSPIUM CHLORIDE 20 MG TABLET N/ATROSPIUM CHLORIDE ER 60 MG CAP N/ATRUEDRAW LANCING DEVICE N/ATRUEPLUS 26G LANCETS N/ATRUEPLUS 30G LANCETS N/ATRUEPLUS 33G LANCETS N/ATRUEPLUS KETONE TEST STRIP N/ATRUEPLUS SAFETY 28G LANCET N/ATRUEPLUS SAFETY 28G LANCETS N/ATRUEPLUS SUPER THIN 28G LANCET N/ATRUEPLUS SYR 0.3ML 29GX1/2'' N/ATRUEPLUS SYR 0.3ML 30GX5/16'' N/ATRUEPLUS SYR 0.3ML 31GX5/16'' N/ATRUEPLUS SYR 0.5ML 28GX1/2'' N/ATRUEPLUS SYR 0.5ML 29GX1/2'' N/ATRUEPLUS SYR 0.5ML 30GX5/16'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

TRUEPLUS SYR 0.5ML 31GX5/16'' N/ATRUEPLUS SYR 1ML 28GX1/2'' N/ATRUEPLUS SYR 1ML 29GX1/2'' N/ATRUEPLUS SYR 1ML 30GX5/16'' N/ATRUEPLUS SYR 1ML 31GX5/16'' N/ATRUEPLUS ULTRA THIN 30G LANCET N/ATRULANCE 3 MG TABLET N/ATRULICITY 0.75 MG/0.5 ML PEN N/ATRULICITY 1.5 MG/0.5 ML PEN N/ATRUMENBA 120 MCG/0.5 ML VACCIN N/ATRUSTEX CONDOM N/ATRUSTEX LATEX CONDOM N/ATRUSTEX-RIA CONDOM N/ATRUVADA 100 MG-150 MG TABLET N/ATRUVADA 133 MG-200 MG TABLET N/ATRUVADA 167 MG-250 MG TABLET N/ATRUVADA 200 MG-300 MG TABLET N/ATRUZONE PEAK FLOW METER N/ATUMS FRESHERS ANTACID CHEW TAB N/ATUSICOF CAPLET N/ATUSICOF LIQUID N/ATUSNEL DIABETIC LIQUID N/ATUSSIN 100 MG/5 ML SYRUP N/ATUSSIN CF COUGH-COLD LIQUID N/ATUSSIN CF COUGH-COLD SYRUP N/ATUSSIN CF MAX M-S COLD LIQUID N/ATUSSIN CF MULTI-SYMPTOM COLD N/ATUSSIN CHEST CONGESTION LIQUID N/ATUSSIN DM CLEAR SYRUP N/ATUSSIN DM LIQUID N/ATUSSIN DM SYRUP N/ATUSSIN MUCUS-CONG 200 MG/10 N/ATUSSI-PRES LIQUID N/A

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TUSSI-PRES LIQUID PACKET N/ATUSSLIN LIQUID N/ATUSSLIN PEDIATRIC DROPS N/ATUTTI FRUTTI FLAVOR LIQUID N/ATWINRIX VACCINE SYRINGE N/ATWIST LANCETS N/ATYBOST 150 MG TABLET N/ATYDEMY TABLET N/ATYKERB 250 MG TABLET N/ATYLENOL 325 MG CAPLET N/ATYLENOL 325 MG TABLET N/ATYLENOL EX-STR 500 MG CAPLET N/ATYLENOL EX-STR 500 MG GELCAP N/ATYMLOS 80 MCG DOSE PEN INJECTR N/ATYVASO 1.74 MG/2.9 ML SOLUTION N/ATYVASO INHALATION REFILL KIT N/ATYVASO INHALATION STARTER KIT N/ATYVASO INSTITUTIONAL START KIT N/AULESFIA 5% LOTION N/AULORIC 40 MG TABLET N/AULORIC 80 MG TABLET N/AULT CFT 0.3 ML 29GX1/2'' (1/2) N/AULT CFT 0.3 ML 30GX5/16'' (1/2) N/AULT CFT 0.3 ML 31GX5/16'' (1/2) N/AULTCARE INS SYR 1 ML 31GX5/16'' N/AULTICARE INS 0.3 ML 30GX1/2'' N/AULTICARE INS 0.5 ML 30GX1/2'' N/AULTICARE INS SAFETY 1ML 29X1/2 N/AULTICARE INS SYR 1 ML 28GX1/2'' N/AULTICARE INS SYR 1 ML 29GX1/2'' N/AULTICARE INS SYR 1 ML 30GX1/2'' N/AULTICARE SAFETY 0.5 ML 29GX1/2 N/AULTICARE SYR 0.3 ML 30GX1/2'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ULTICARE SYR 0.3 ML 30GX5/16'' N/AULTICARE SYR 0.3 ML 31GX5/16'' N/AULTICARE SYR 0.5 ML 29GX1/2'' N/AULTICARE SYR 0.5 ML 30GX1/2'' N/AULTICARE SYR 0.5 ML 30GX5/16'' N/AULTICARE SYR 0.5 ML 31GX5/16'' N/AULTICARE SYR 1 ML 30GX5/16'' N/AULTICARE SYR 1 ML 31GX5/16'' N/AULTICARE SYRIN 0.3 ML 29GX1/2'' N/AULTICARE SYRIN 0.5 ML 28GX1/2'' N/AULTICARE SYRINGE 1 ML 30GX1/2'' N/AULTI-LANCE AUTOMATIC DEVICE N/AULTILET 28G LANCETS N/AULTILET 30G LANCETS N/AULTILET 33G LANCETS N/AULTILET CLASSIC 26G LANCETS N/AULTILET CLASSIC 28G LANCETS N/AULTILET CLASSIC 30G LANCETS N/AULTILET CLASSIC 33G LANCETS N/AULTILET PEN NEEDLE N/AULTILET PEN NEEDLE 4MM 32G N/AULTILET SAFETY 23G LANCETS N/AULTRA COMFORT 0.3 ML 29GX1/2'' N/AULTRA COMFORT 0.3 ML SYRINGE N/AULTRA COMFORT 0.5 ML 28GX1/2'' N/AULTRA COMFORT 0.5 ML 29GX1/2'' N/AULTRA COMFORT 0.5 ML 30GX5/16'' N/AULTRA COMFORT 0.5 ML 31GX5/16'' N/AULTRA COMFORT 0.5 ML SYRINGE N/AULTRA COMFORT 1 ML 28GX1/2'' N/AULTRA COMFORT 1 ML 29GX1/2'' N/AULTRA COMFORT 1 ML 30GX5/16'' N/AULTRA COMFORT 1 ML 31GX5/16'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ULTRA COMFORT 1 ML SYRINGE N/AULTRA FREEDA TABLET N/AULTRA FREEDA WITH IRON TABLET N/AULTRA FRESH 0.5% EYE DROP N/AULTRA THIN 28G LANCETS N/AULTRA THIN 30G LANCETS N/AULTRA THIN 31G LANCETS N/AULTRA THIN 33G LANCETS N/AULTRA-THIN II 1 ML 31GX5/16'' N/AULTRA-THIN II 28G LANCETS N/AULTRA-THIN II 30G LANCETS N/AULTRA-THIN II INS 0.3 ML 30G N/AULTRA-THIN II INS 0.3 ML 31G N/AULTRA-THIN II INS 0.5 ML 29G N/AULTRA-THIN II INS 0.5 ML 30G N/AULTRA-THIN II INS 0.5 ML 31G N/AULTRA-THIN II INS SYR 1 ML 29G N/AULTRA-THIN II INS SYR 1 ML 30G N/AUNICOMPLEX-M TABLET N/AUNIFINE PENTIPS 12MM 29G N/AUNIFINE PENTIPS 31GX3/16'' N/AUNIFINE PENTIPS 32GX5/32'' N/AUNIFINE PENTIPS 6MM 31G N/AUNIFINE PENTIPS 6MM NEEDLE N/AUNIFINE PENTIPS 8MM 31G N/AUNIFINE PENTIPS 8MM NEEDLE N/AUNIFINE PENTIPS NEEDLES 29G N/AUNIFINE PENTIPS PLUS 29GX1/2'' N/AUNIFINE PENTIPS PLUS 31GX1/4'' N/AUNIFINE PENTIPS PLUS 31GX3/16'' N/AUNIFINE PENTIPS PLUS 31GX5/16'' N/AUNIFINE PENTIPS PLUS 32GX5/32'' N/AUNIFINE PENTIPS PLUS 33GX5/32'' N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

UNILET COMFORTOUCH 26G LANCETS N/AUNILET COMFORTOUCH LANCET N/AUNILET EXCELITE II LANCET N/AUNILET EXCELITE LANCET N/AUNILET GP LANCET N/AUNILET GP LANCET SUPERLITE N/AUNILET MICRO THIN 33G LANCETS N/AUNILET SUPER THIN 30G LANCETS N/AUNILET ULTRA THIN 28G LANCETS N/AUNISOM 25 MG SLEEPTABS N/AUNISOM SLEEP AID 25 MG TABLET N/AUNISTIK 2 NORMAL 0.81MM DEVICE N/AUNISTIK 3 GENTLE 30G LANCETS N/AUNISTIK 3 GENTLE ON-THE-GO 30G N/AUNISTIK SAFETY 28G LANCET N/AUNISTIK SAFETY 30G LANCETS N/AUNISTIK TOUCH 21G LANCETS N/AUNISTIK TOUCH 23G LANCETS N/AUNISTIK TOUCH 28G LANCETS N/AUNISTIK TOUCH 30G LANCETS N/AUNITHROID 100 MCG TABLET N/AUNITHROID 112 MCG TABLET N/AUNITHROID 125 MCG TABLET N/AUNITHROID 137 MCG TABLET N/AUNITHROID 150 MCG TABLET N/AUNITHROID 175 MCG TABLET N/AUNITHROID 200 MCG TABLET N/AUNITHROID 25 MCG TABLET N/AUNITHROID 300 MCG TABLET N/AUNITHROID 50 MCG TABLET N/AUNITHROID 75 MCG TABLET N/AUNITHROID 88 MCG TABLET N/AUNIVERSAL 1 33G LANCETS N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

UP&UP GLUCOSE 4 GRAM TAB CHEW N/AUREA 40% CREAM N/AURISTIX 4 REAGENT STRIPS N/AURISTIX REAGENT STRIPS N/AURSODIOL 250 MG TABLET N/AURSODIOL 300 MG CAPSULE N/AURSODIOL 500 MG TABLET N/AVALACYCLOVIR HCL 1 GRAM TABLET N/AVALACYCLOVIR HCL 500 MG TABLET N/AVALGANCICLOVIR 450 MG TABLET N/AVALGANCICLOVIR HCL 50 MG/ML N/AVALSARTAN 160 MG TABLET N/AVALSARTAN 320 MG TABLET N/AVALSARTAN 40 MG TABLET N/AVALSARTAN 80 MG TABLET N/AVALSARTAN-HCTZ 160-12.5 MG TAB N/AVALSARTAN-HCTZ 160-25 MG TAB N/AVALSARTAN-HCTZ 320-12.5 MG TAB N/AVALSARTAN-HCTZ 320-25 MG TAB N/AVALSARTAN-HCTZ 80-12.5 MG TAB N/AVALUE PLUS LANCING DEVICE N/AVANACOF DM 18-200-10 MG/15 ML N/AVANCOCIN HCL 125 MG CAPSULE N/AVANCOMYCIN HCL 125 MG CAPSULE N/AVANCOMYCIN HCL 250 MG CAPSULE N/AVANCOMYCIN HCL POWDER N/AVANDAZOLE VAGINAL 0.75% GEL N/AVANILLA BUTTERNUT FLAVOR LIQ N/AVANILLA EXTRACT FLAVOR LIQUID N/AVANILLA FLAVOR LIQUID N/AVANISHPOINT 0.5 ML 30GX1/2'' SY N/AVANISHPOINT 22GX1'' 3 ML SYR N/AVANISHPOINT U-100 29X1/2 SYR N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

VANTAGE LANCING DEVICE N/AVAQTA 25 UNITS/0.5 ML SYRINGE N/AVAQTA 50 UNITS/ML SYRINGE N/AVARIVAX VACCINE VIAL N/AVARIVAX VACCINE WITH DILUENT N/AVECTICAL 3 MCG/G OINTMENT N/AVELETRI 0.5 MG VIAL N/AVELETRI 1.5 MG VIAL N/AVELIVET 28 DAY TABLET N/AVEMLIDY 25 MG TABLET N/AVENTAVIS 10 MCG/1 ML SOLUTION N/AVENTAVIS 20 MCG/1 ML SOLUTION N/AVERAPAMIL 120 MG TABLET N/AVERAPAMIL 360 MG CAP PELLET N/AVERAPAMIL 40 MG TABLET N/AVERAPAMIL 80 MG TABLET N/AVERAPAMIL ER 120 MG CAPSULE N/AVERAPAMIL ER 120 MG TABLET N/AVERAPAMIL ER 180 MG CAPSULE N/AVERAPAMIL ER 180 MG TABLET N/AVERAPAMIL ER 240 MG CAPSULE N/AVERAPAMIL ER 240 MG TABLET N/AVERAPAMIL ER PM 100 MG CAPSULE N/AVERAPAMIL ER PM 200 MG CAPSULE N/AVERAPAMIL ER PM 300 MG CAPSULE N/AVERAPAMIL HCL POWDER N/AVERAPAMIL SR 120 MG CAPSULE N/AVERAPAMIL SR 180 MG CAPSULE N/AVERAPAMIL SR 240 MG CAPSULE N/AVERSA FREE SF SYRUP VEHICLE N/AVERSA PLUS SUSPENSION VEHICLE N/AVIBERZI 100 MG TABLET N/AVIBERZI 75 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

VICKS QLEARQUIL 0.05% MIST N/AVIGAMOX 0.5% EYE DROPS N/AVINATE ONE TABLET N/AVINATE-M TABLET N/AVIORELE 28 DAY TABLET N/AVIRACEPT 250 MG TABLET N/AVIRACEPT 625 MG TABLET N/AVIRAMUNE 200 MG TABLET N/AVIRAMUNE 50 MG/5 ML SUSP N/AVIRAMUNE XR 400 MG TABLET N/AVIREAD 150 MG TABLET N/AVIREAD 200 MG TABLET N/AVIREAD 250 MG TABLET N/AVIREAD 300 MG TABLET N/AVIREAD POWDER N/AVIRTUSSIN AC 10-100 MG/5 ML LQ N/AVIRTUSSIN AC W-ALC 10-100 MG/5 N/AVIRTUSSIN DAC LIQUID N/AVISION PLUS LUTEIN VITAMIN TAB N/AVISION VITAMINS TABLET N/AVIT A;C;D-FLUORIDE 0.25 MG/ML N/AVIT A;C;D-FLUORIDE 0.5 MG/ML N/AVIT D3 125 MCG (5000 UNIT) TAB N/AVITACEL TABLET N/AVITAFOL-OB CAPLET N/AVITAJOY DAILY D GUMMY N/AVITAMIN AND MINERALS TABLET N/AVITAMIN B COMPLEX-VIT C CAPLET N/AVITAMIN B COMPLEX-VITAMIN C TB N/AVITAMIN B-6 100 MG TABLET N/AVITAMIN B-6 25 MG TABLET N/AVITAMIN B-6 250 MG TABLET N/AVITAMIN B-6 50 MG TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

VITAMIN B-COMPLEX & C CAPLET N/AVITAMIN D2 1.25MG(50;000 UNIT) N/AVITAMIN D2 400 UNIT TABLET N/AVITAMIN D3 1;000 UNIT GUMMIES N/AVITAMIN D3 1;000 UNIT GUMMY N/AVITAMIN D3 1;000 UNIT SOFTGEL N/AVITAMIN D3 1;000 UNIT TAB CHEW N/AVITAMIN D3 1;000 UNIT TABLET N/AVITAMIN D3 10 MCG/ML LIQUID N/AVITAMIN D3 10;000 UNIT SOFTGEL N/AVITAMIN D3 125 MCG (5000 UNIT) N/AVITAMIN D3 125 MCG CAPSULE N/AVITAMIN D3 2;000 UNIT SOFTGEL N/AVITAMIN D3 2;000 UNIT TABLET N/AVITAMIN D3 25 MCG (1;000 UNIT) N/AVITAMIN D3 25 MCG SOFTGEL N/AVITAMIN D3 25 MCG TABLET N/AVITAMIN D3 3;000 UNIT TABLET N/AVITAMIN D3 400 UNIT SOFTGEL N/AVITAMIN D3 400 UNIT TAB CHEW N/AVITAMIN D3 400 UNIT TABLET N/AVITAMIN D3 400 UNIT/5 ML LIQ N/AVITAMIN D3 5;000 UNIT CAPSULE N/AVITAMIN D3 5;000 UNIT SOFTGEL N/AVITAMIN D3 5;000 UNIT TABLET N/AVITAMIN D3 5;000 UNIT/ML DROPS N/AVITAMIN D3 50 MCG (2;000 UNIT) N/AVITAMIN D3 50 MCG TABLET N/AVITAMIN D3 50;000 UNIT CAPSULE N/AVITAMIN D3 COMPLETE CAPLET N/AVITAMIN D-400 TABLET N/AVITAMINS A-D-E TABLET N/AVITATRUM TABLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

VITRUM 50 PLUS SENIOR TABLET N/AVITRUM SENIOR TABLET N/AVORTEX HOLDING CHAMBER N/AVORTEX HOLDING CHAMBER-CHILD N/AVORTEX HOLDING CHAMBER-TODDLER N/AVOTRIENT 200 MG TABLET N/AV-R ALCOHOL PREP PADS N/AVYFEMLA 28 TABLET N/AVYNDAQEL 20 MG CAPSULE N/AVYTORIN 10-10 MG TABLET N/AVYTORIN 10-20 MG TABLET N/AVYTORIN 10-40 MG TABLET N/AVYTORIN 10-80 MG TABLET N/AWAL-DRYL ALLERGY 12.5 MG/5 ML N/AWAL-DRYL ALLERGY 25 MG CAPSULE N/AWAL-DRYL ALLERGY 25 MG MINITAB N/AWAL-DRYL ALLERGY 25 MG SOFTGEL N/AWAL-FEX ALLERGY 180 MG TABLET N/AWAL-FEX ALLERGY 60 MG TABLET N/AWAL-FEX D 12 HOUR 60-120 TAB N/AWAL-FEX D 24 HOUR 180-240 TAB N/AWAL-FINATE 4 MG TABLET N/AWAL-FINATE-D TABLET N/AWALGREENS THIN LANCETS N/AWALGREENS ULTRA THIN LANCETS N/AWAL-ITIN 10 MG TABLET N/AWAL-ITIN 5 MG/5 ML SYRUP N/AWAL-ITIN D 24 HOUR TABLET N/AWAL-MUCIL 0.52 G CAPSULE N/AWAL-MUCIL 100% NATURAL FIBER N/AWAL-MUCIL NTRL FIBER LAX POWD N/AWAL-PHED SINUS AND ALLERGY TAB N/AWAL-PROFEN 200 MG CAPLET N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

WAL-PROFEN 200 MG TABLET N/AWAL-SOM 25 MG TABLET N/AWAL-ZYR 0.025% EYE DROPS N/AWAL-ZYR 10 MG TABLET N/AWAL-ZYR D TABLET N/AWAL-ZYR SOLUTION N/AWARFARIN SODIUM 1 MG TABLET N/AWARFARIN SODIUM 10 MG TABLET N/AWARFARIN SODIUM 2 MG TABLET N/AWARFARIN SODIUM 2.5 MG TABLET N/AWARFARIN SODIUM 3 MG TABLET N/AWARFARIN SODIUM 4 MG TABLET N/AWARFARIN SODIUM 5 MG TABLET N/AWARFARIN SODIUM 6 MG TABLET N/AWARFARIN SODIUM 7.5 MG TABLET N/AWARFARIN SODIUM POWDER N/AWART REMOVER 17% LIQUID N/AWART REMOVER LIQUID N/AWART REMOVER SOLUTION N/AWATER FOR INJECTION VIAL N/AWATERMELON FLAVOR N/AWATERMELON FLAVOR LIQUID N/AWEBCOL ALCOHOL PREPS N/AWERA 0.5/0.035 MG 28 TABLET N/AWESTHROID 130 MG TABLET N/AWHITE PETROLATUM JELLY N/AWHITE PETROLEUM JELLY N/AWIDE SEAL DIAPHRAGM 65MM N/AWIDE SEAL DIAPHRAGM 70MM N/AWIDE SEAL DIAPHRAGM 75MM N/AWIDE SEAL DIAPHRAGM 80MM N/AWIDE SEAL DIAPHRAGM 85MM N/AWILD CHERRY FLAVOR CONC LIQUID N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

WINRHO SDF 1;500 UNIT VIAL N/AWINRHO SDF 15;000 UNIT VIAL N/AWINRHO SDF 2;500 UNIT VIAL N/AWINRHO SDF 5;000 UNIT VIAL N/AWIXELA 100-50 INHUB N/AWIXELA 250-50 INHUB N/AWIXELA 500-50 INHUB N/AWM UNIFINE PENTIP PLUS 4MM 32G N/AWM UNIFINE PENTIP PLUS 5MM 31G N/AWM UNIFINE PENTIP PLUS 6MM 31G N/AWM UNIFINE PENTIP PLUS 8MM 31G N/AWOMEN'S DAILY CAPLET N/AWOMEN'S DAILY FORMULA CAPLET N/AWP THYROID 130 MG TABLET N/AWYMZYA FE CHEWABLE TABLET N/AXALKORI 200 MG CAPSULE N/AXALKORI 250 MG CAPSULE N/AXANTHAN GUM POWDER N/AXOFLUZA 20 MG TAB (40 MG DOSE) N/AXOFLUZA 40 MG TAB (80 MG DOSE) N/AX-SEB T PLUS SHAMPOO N/AXTANDI 40 MG CAPSULE N/AXULANE PATCH N/AYELETS TABLET N/AYUVAFEM 10 MCG VAGINAL INSERT N/AZAFIRLUKAST 10 MG TABLET N/AZAFIRLUKAST 20 MG TABLET N/AZARAH TABLET N/AZEBUTAL 50-325-40 MG CAPSULE N/AZEGERID 20 MG PACKET N/AZELBORAF 240 MG TABLET N/AZENATANE 10 MG CAPSULE N/AZENATANE 20 MG CAPSULE N/A

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Prescription Drug Formulary Prior Authorization (PA) NQTL Fail First/Step Therapy (FF/ST) NQTLMed/Surg Drugs Med/Surg Drugs

ZENATANE 30 MG CAPSULE N/AZENATANE 40 MG CAPSULE N/AZIAGEN 20 MG/ML SOLUTION N/AZIAGEN 300 MG TABLET N/AZIDOVUDINE 100 MG CAPSULE N/AZIDOVUDINE 300 MG TABLET N/AZIDOVUDINE 50 MG/5 ML SYRUP N/AZOLMITRIPTAN 2.5 MG ODT N/AZOLMITRIPTAN 2.5 MG TABLET N/AZOLMITRIPTAN 5 MG ODT N/AZOLMITRIPTAN 5 MG TABLET N/AZOMIG 5 MG NASAL SPRAY N/AZOSTAVAX VIAL N/AZOVIA 1-35E TABLET N/A