Appendix F4. Jai Medical Systems (Jai).xlsx - Maryland.gov

203
Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System Prior Authorization (PA) NQTL Step Therapy/Fail First (ST/FF) NQTL Med/Surg Drugs Med/Surg Drugs ABACAVIR 300 MG TABLET ABACAVIR ORAL SOLUTION 20 MG/ML ABACAVIR-LAMIVUDINE 600-300 MG ABACAVIR-LAMIVUDINE-ZIDOV TAB ACARBOSE 100 MG TABLET ACARBOSE 100 MG TABLET ACARBOSE 100 MG TABLET ACARBOSE 25 MG TABLET ACARBOSE 25 MG TABLET ACARBOSE 25 MG TABLET ACARBOSE 50 MG TABLET ACARBOSE 50 MG TABLET ACARBOSE 50 MG TABLET ACETAMINOPHEN 160 MG RAPID TAB ACETAMINOPHEN 160 MG/5 ML ELIX ACETAMINOPHEN 160 MG/5 ML ELX ACETAMINOPHEN 160 MG/5 ML LIQ ACETAMINOPHEN 160 MG/5 ML SOL ACETAMINOPHEN 160 MG/5 ML SUSP ACETAMINOPHEN 325 MG GELCAP ACETAMINOPHEN 325 MG LIQUI-GEL ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG/10.15 ML ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG GELCAP ACETAMINOPHEN 500 MG SOFTGEL ACETAMINOPHEN 500 MG TABLET ACETAMINOPHEN 650 MG/20.3 ML ACETAMINOPHEN 80 MG RAPID TAB ACETAMINOPHEN 80 MG TAB CHEW ACETAMINOPHEN 80 MG/0.8 ML DRP ACETAMINOPHEN ER 650 MG TABLET ACETAMINOPHEN INFANT DROPS ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-COD #4 TABLET Prescription Drug Formulary F4 1

Transcript of Appendix F4. Jai Medical Systems (Jai).xlsx - Maryland.gov

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ABACAVIR 300 MG TABLETABACAVIR ORAL SOLUTION 20 MG/MLABACAVIR-LAMIVUDINE 600-300 MGABACAVIR-LAMIVUDINE-ZIDOV TABACARBOSE 100 MG TABLET ACARBOSE 100 MG TABLET ACARBOSE 100 MG TABLETACARBOSE 25 MG TABLET ACARBOSE 25 MG TABLET ACARBOSE 25 MG TABLETACARBOSE 50 MG TABLET ACARBOSE 50 MG TABLET ACARBOSE 50 MG TABLETACETAMINOPHEN 160 MG RAPID TABACETAMINOPHEN 160 MG/5 ML ELIXACETAMINOPHEN 160 MG/5 ML ELXACETAMINOPHEN 160 MG/5 ML LIQACETAMINOPHEN 160 MG/5 ML SOLACETAMINOPHEN 160 MG/5 ML SUSPACETAMINOPHEN 325 MG GELCAPACETAMINOPHEN 325 MG LIQUI-GELACETAMINOPHEN 325 MG TABLETACETAMINOPHEN 325 MG/10.15 MLACETAMINOPHEN 500 MG CAPLETACETAMINOPHEN 500 MG GELCAPACETAMINOPHEN 500 MG SOFTGELACETAMINOPHEN 500 MG TABLETACETAMINOPHEN 650 MG/20.3 MLACETAMINOPHEN 80 MG RAPID TABACETAMINOPHEN 80 MG TAB CHEWACETAMINOPHEN 80 MG/0.8 ML DRPACETAMINOPHEN ER 650 MG TABLETACETAMINOPHEN INFANT DROPSACETAMINOPHEN-COD #2 TABLETACETAMINOPHEN-COD #3 TABLETACETAMINOPHEN-COD #4 TABLET

Prescription Drug Formulary

F4 1

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ACETAMINOPHEN-CODEINE 120 MG-1ACETAMINOPHEN-CODEINE 120-12 MACETAMINOPHEN-CODEINE 300-30 MACETAZOLAMIDE 125 MG TABLETACETAZOLAMIDE 250 MG TABLETACETYLCYSTEINE 10% VIALACETYLCYSTEINE 20% VIALACETYLCYSTEINE 6 GRAM/30 ML VLACID CONTROL 150 MG TABLETACID REDUCER 10 MG TABLETACID REDUCER 150 MG TABLETACID REDUCER 20 MG TABLETACID REDUCER 75 MG TABLETACTIVATED CHARCOAL POWDERACYCLOVIR 200 MG/5 ML SUSP ACYCLOVIR 200 MG/5 ML SUSPACYCLOVIR 5% CREAM ACYCLOVIR 5% CREAMACYCLOVIR 5% OINTMENT ACYCLOVIR 5% OINTMENTACYCLOVIR 800 MG TABLETADAPALENE 0.1% CREAMADAPALENE 0.1% GELADAPALENE 0.3% GELADMELOG ADULT COUGH FORMULA DM MAX LIQADULT MULTIVITAMIN EXTRA D3ADULT MULTIVITAMIN-IRON TABLETADVAIR 100-50 DISKUS ADVAIR 100-50 DISKUS ADVAIR 100-50 DISKUSADVAIR 250-50 DISKUS ADVAIR 250-50 DISKUS ADVAIR 250-50 DISKUSADVAIR 500-50 DISKUS ADVAIR 500-50 DISKUS ADVAIR 500-50 DISKUSADVAIR HFA 115-21 MCG INHALER ADVAIR HFA 115-21 MCG INHALERADVAIR HFA 115-21 MCG INHALER

F4 2

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ADVAIR HFA 230-21 MCG INHALER ADVAIR HFA 230-21 MCG INHALERADVAIR HFA 230-21 MCG INHALERADVAIR HFA 45-21 MCG INHALER ADVAIR HFA 45-21 MCG INHALERADVAIR HFA 45-21 MCG INHALERADVICOR 1,000 MG-20 MG TABLETADVICOR 1,000 MG-40 MG TABLETADVICOR 500 MG-20 MG TABLETADVICOR 750 MG-20 MG TABLETAFIRMELLE-28 TABLETAIMSCO LATEX CONDOMAK-POLY-BAC EYE OINTMENTALBENDAZOLE 200 MG TABLETALBENZA 200 MG TABLETALBUTEROL 2.5 MG/0.5 ML SOLALBUTEROL 5 MG/ML SOLUTIONALBUTEROL HFA 90 MCG INHALERALBUTEROL SUL 1.25 MG/3 ML SOLALBUTEROL SUL 2.5 MG/3 ML SOLNALCOHOL 70% PADSALCOHOL 70% PREP PADSALCOHOL 70% SWABSALCOHOL PREP PADSALCOHOL PREP SWABSALCOHOL SWABALCOHOL SWABSALDACTAZIDE 25-25 TABLETALDACTAZIDE 50-50 TABLETALENDRONATE SOD 70 MG/75 MLALENDRONATE SODIUM 10 MG TABALENDRONATE SODIUM 35 MG TABALENDRONATE SODIUM 40 MG TAB

F4 3

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ALENDRONATE SODIUM 5 MG TABLETALENDRONATE SODIUM 70 MG TABALFERON N 5 MILLION UNITS VIAL ALFERON N 5 MILLION UNITS VIALALKERAN 2 MG TABLETALKERAN 50 MG VIALALLOPURINOL 100 MG TABLETALLOPURINOL 300 MG TABLETALOMIDE 0.1% EYE DROPS ALOMIDE 0.1% EYE DROPSALTAVERA-28 TABLETALUMINUM HYDROXIDE GELALYACEN 1-35 28 TABLETALYACEN 7-7-7-28 TABLETAMANTADINE 100 MG CAPSULEAMANTADINE 100 MG TABLETAMANTADINE 100 MG/10 ML SOLNAMANTADINE 50 MG/5 ML SOLUTIONAMETHIA 0.15-0.03-0.01 MG TABAMETHIA LO TABLETAMETHYST 90-20 MCG TABLETAMINOPHYLLINE 250 MG/10 ML VLAMINOPHYLLINE 500 MG/20 ML VLAMIODARONE 150 MG/3 ML AMPAMIODARONE 150 MG/3 ML SYRINGEAMIODARONE 150 MG/3 ML VIALAMIODARONE 450 MG/9 ML VIALAMIODARONE 900 MG/18 ML VIALAMIODARONE HCL 100 MG TABLETAMIODARONE HCL 200 MG TABLETAMIODARONE HCL 400 MG TABLET

F4 4

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

AMITIZA 24 MCG CAPSULES AMITIZA 24 MCG CAPSULES AMITIZA 24 MCG CAPSULESAMITIZA 8 MCG CAPSULE AMITIZA 8 MCG CAPSULE AMITIZA 8 MCG CAPSULEAMLODIPINE BESYLATE 10 MG TABAMLODIPINE BESYLATE 2.5 MG TABAMLODIPINE BESYLATE 5 MG TABAMLODIPINE-ATORVAST 10-10 MGAMLODIPINE-ATORVAST 10-20 MGAMLODIPINE-ATORVAST 10-40 MGAMLODIPINE-ATORVAST 10-80 MGAMLODIPINE-ATORVAST 2.5-10 MGAMLODIPINE-ATORVAST 2.5-20 MGAMLODIPINE-ATORVAST 2.5-40 MGAMLODIPINE-ATORVAST 5-10 MGAMLODIPINE-ATORVAST 5-20 MGAMLODIPINE-ATORVAST 5-40 MGAMLODIPINE-ATORVAST 5-80 MGAMLODIPINE-BENAZEPRIL 10-20 MGAMLODIPINE-BENAZEPRIL 10-40 MGAMLODIPINE-BENAZEPRIL 2.5-10AMLODIPINE-BENAZEPRIL 5-10 MGAMLODIPINE-BENAZEPRIL 5-20 MGAMLODIPINE-BENAZEPRIL 5-40 MGAMMONIUM LACTATE 12% CREAMAMMONIUM LACTATE 12% LOTIONAMOX-CLAV 200-28.5 MG/5 ML SUSAMOX-CLAV 250-125 MG TABLETAMOX-CLAV 250-62.5 MG/5 ML SUSAMOX-CLAV 400-57 MG/5 ML SUSPAMOX-CLAV 500-125 MG TABLET

F4 5

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

AMOX-CLAV 600-42.9 MG/5 ML SUSAMOX-CLAV 875-125 MG TABLETAMOX-CLAV ER 1,000-62.5 MG TABAMOXICILLIN 125 MG/5 ML SUSPAMOXICILLIN 200 MG/5 ML SUSPAMOXICILLIN 250 MG CAPSULEAMOXICILLIN 250 MG/5 ML SUSPAMOXICILLIN 400 MG/5 ML SUSPAMOXICILLIN 500 MG CAPSULEAMOXICILLIN 500 MG TABLETAMOXICILLIN 875 MG TABLETAMOXICILLIN ER 775 MG TABLETAMPICILLIN 125 MG/5 ML SUSPAMPICILLIN 250 MG CAPSULEAMPICILLIN 250 MG/5 ML SUSPAMPICILLIN 500 MG CAPSULEAMPYRA ER 10 MG TABLET AMPYRA ER 10 MG TABLET AMPYRA ER 10 MG TABLETANASTROZOLE 1 MG TABLETANDROGEL 1% GEL PUMP ANDROGEL 1% GEL PUMPANDROGEL 1%(2.5G) GEL PACKET ANDROGEL 1%(2.5G) GEL PACKETANDROGEL 1%(5G) GEL PACKET ANDROGEL 1%(5G) GEL PACKETANDROGEL 1.62% GEL PUMP ANDROGEL 1.62% GEL PUMPANDROGEL 1.62%(1.25G) GEL PCKT ANDROGEL 1.62%(1.25G) GEL PCKTANDROGEL 1.62%(2.5G) GEL PCKT ANDROGEL 1.62%(2.5G) GEL PCKTANDROID 10 MG CAPSULEANORO ELLIPTA 62.5-25 MCG INH ANORO ELLIPTA 62.5-25 MCG INHANORO ELLIPTA 62.5-25 MCG INHANTACID LIQUIDANTARA 130 MG CAPSULE ANTARA 130 MG CAPSULE ANTARA 130 MG CAPSULEANTARA 30 MG CAPSULE ANTARA 30 MG CAPSULE ANTARA 30 MG CAPSULE

F4 6

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ANTARA 43 MG CAPSULE ANTARA 43 MG CAPSULE ANTARA 43 MG CAPSULEANTARA 90 MG CAPSULE ANTARA 90 MG CAPSULE ANTARA 90 MG CAPSULEANTIBIOTIC OINTMENTANTI-DIARRHEAL 1 MG/5 ML LIQANTI-DIARRHEAL 1 MG/7.5 ML SOLANTI-DIARRHEAL 1 MG/7.5 ML SUSANTI-DIARRHEAL 2 MG CAPLETANTI-DIARRHEAL 2 MG SOFTGELANTI-DIARRHEAL 2 MG TABLETANTIFUNGAL 1% CREAMANTIFUNGAL 1% TOPICAL CREAMANTIFUNGAL 2% TOPICAL CREAMANTI-ITCH 1% CREAMANTI-ITCH 1% OINTMENTANTIPYRINE-BENZOCAINE EAR DROPANTIPYRINE-BENZOCAINE OTIC SOLANUSOL-HC 2.5% CREAMAPREPITANT 125 MG CAPSULE APREPITANT 125 MG CAPSULEAPREPITANT 125-80-80 MG PACK APREPITANT 125-80-80 MG PACKAPREPITANT 40 MG CAPSULE APREPITANT 40 MG CAPSULEAPREPITANT 80 MG CAPSULE APREPITANT 80 MG CAPSULEAPRI 28 DAY TABLETAQUADEKS CHEWABLE TABLETARANELLE 28 TABLETARANESP 10 MCG/0.4 ML SYRINGE ARANESP 10 MCG/0.4 ML SYRINGEARANESP 100 MCG/0.5 ML SYRINGE ARANESP 100 MCG/0.5 ML SYRINGEARANESP 100 MCG/ML VIAL ARANESP 100 MCG/ML VIALARANESP 150 MCG/0.3 ML SYRINGE ARANESP 150 MCG/0.3 ML SYRINGEARANESP 150 MCG/0.75 ML VIAL ARANESP 150 MCG/0.75 ML VIAL

F4 7

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ARANESP 200 MCG/0.4 ML SYRINGE ARANESP 200 MCG/0.4 ML SYRINGEARANESP 200 MCG/ML VIAL ARANESP 200 MCG/ML VIALARANESP 25 MCG/0.42 ML SYRING ARANESP 25 MCG/0.42 ML SYRINGARANESP 25 MCG/ML VIAL ARANESP 25 MCG/ML VIALARANESP 300 MCG/0.6 ML SYRINGE ARANESP 300 MCG/0.6 ML SYRINGEARANESP 300 MCG/ML VIAL ARANESP 300 MCG/ML VIALARANESP 40 MCG/0.4 ML SYRINGE ARANESP 40 MCG/0.4 ML SYRINGEARANESP 40 MCG/ML VIAL ARANESP 40 MCG/ML VIALARANESP 500 MCG/1 ML SYRINGE ARANESP 500 MCG/1 ML SYRINGEARANESP 60 MCG/0.3 ML SYRINGE ARANESP 60 MCG/0.3 ML SYRINGEARANESP 60 MCG/ML VIAL ARANESP 60 MCG/ML VIALASHLYNA 0.15-0.03-0.01 MG TABASPIR EC 81 MG TABLETASPIRIN 325 MG TABLETASPIRIN 81 MG CHEWABLE TABLETASPIRIN ADULT 81 MG CHEW TABASPIRIN BUFFERED 325 MG TABASPIRIN EC 325 MG TABLETASPIRIN EC 500 MG TABLETASPIRIN EC 650 MG TABLETASPIRIN EC 81 MG TABLETASPIRIN NON IRRIT 325 MG TABASPIR-LOW EC 81 MG TABLETATABEX EC CAPLETATABEX OB TABLETATAZANAVIR SULFATE 150 MG CAPATAZANAVIR SULFATE 300 MG CAPATENOLOL 100 MG TABLETATENOLOL 25 MG TABLET

F4 8

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ATENOLOL 50 MG TABLETATENOLOL-CHLORTHALIDONE 100-25ATENOLOL-CHLORTHALIDONE 50-25ATHLETE'S FOOT 1% CREAMATORVASTATIN 10 MG TABLETATORVASTATIN 20 MG TABLETATORVASTATIN 40 MG TABLETATORVASTATIN 80 MG TABLETATOVAQUONE 750 MG/5 ML SUSPATRIPLA TABLETATROPINE 0.05 MG/ML SYRINGEATROPINE 0.1 MG/ML SYRINGEATROPINE 0.4 MG/ML VIALATROPINE 0.5 MG/5 ML ABBOJECTATROPINE 0.8 MG/2 ML SYRINGEATROPINE 1 MG/10 ML ABBOJECTATROPINE 1 MG/10 ML SYRINGEATROPINE 1 MG/ML VIALATROPINE 1% EYE DROPSATROPINE 1% EYE OINTMENTATROPINE 2 MG/5 ML SYRINGE (CMATROPINE 8 MG/20 ML VIALATROPINE SULFATE 0.01% EYE DROATROVENT 17 MCG HFA INHALERAUBAGIO 14 MG TABLET AUBAGIO 14 MG TABLETAUBAGIO 7 MG TABLET AUBAGIO 7 MG TABLETAUBRA EQ-28 TABLETAUBRA-28 TABLETAUROVELA 1 MG-20 MCG TABLET

F4 9

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

AUROVELA 21 1.5-30 TABLETAUROVELA 24 FE 1 MG-20 MCG TABAUROVELA FE 1.5 MG-30 MCG TABAUROVELA FE 1-20 TABLETAVC 15% CREAMAVIANE-28 TABLETAVONEX 30 MCG VIAL KIT AVONEX 30 MCG VIAL KITAVONEX PEN 30 MCG/0.5 ML AVONEX PEN 30 MCG/0.5 MLAVONEX PEN 30 MCG/0.5 ML KIT AVONEX PEN 30 MCG/0.5 ML KITAVONEX PREFILLED SYR 30 MCG AVONEX PREFILLED SYR 30 MCGAVONEX PREFILLED SYR 30 MCG KI AVONEX PREFILLED SYR 30 MCG KIAYUNA-28 TABLETAZATHIOPRINE 50 MG TABLETAZELASTINE 0.1% (137 MCG) SPRY AZELASTINE 0.1% (137 MCG) SPRYAZELASTINE 0.1% (137 MCG) SPRYAZELASTINE 0.15% NASAL SPRAY AZELASTINE 0.15% NASAL SPRAYAZELASTINE 0.15% NASAL SPRAYAZELASTINE HCL 0.05% DROPS AZELASTINE HCL 0.05% DROPS AZELASTINE HCL 0.05% DROPSAZITHROMYCIN 1 GM PWD PACKETAZITHROMYCIN 100 MG/5 ML SUSPAZITHROMYCIN 200 MG/5 ML SUSPAZITHROMYCIN 250 MG TABLETAZITHROMYCIN 500 MG ADD-VAN VLAZITHROMYCIN 500 MG TABLETAZITHROMYCIN 600 MG TABLETAZITHROMYCIN I.V. 500 MG VIALAZURETTE 28 DAY TABLETB-1 100 MG TABLETB-12 1,000 MCG TABLETBABY IRON-MULTIVITAMIN DROPBACITRACIN 500 UNIT/GM OINTMNT

F4 10

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

BACITRACIN 500 UNIT/GM OPHTHALBACITRACIN ZN 500 UNIT/GM OINTBACITRACIN-POLYMYXIN EYE OINTBACLOFEN 10 MG TABLETBACLOFEN 10 MG/20 ML VIALBACLOFEN 20 MG TABLETBACLOFEN 20,000 MCG/20 ML VIALBACLOFEN 40 MG/20 ML VIALBACLOFEN 5 MG TABLETBACTROBAN NASAL 2% OINTMENTBALZIVA 28 TABLETBANOPHEN 12.5 MG/5 ML SOLUTIONBANOPHEN 25 MG CAPSULEBANOPHEN 25 MG TABLETBANOPHEN 50 MG CAPSULEBANOPHEN ALLERGY 12.5 MG/5 MLBASAGLAR 100 UNIT/ML KWIKPENBAYER ASPIRIN 325 MG TABLETB-COMPLEX WITH VIT C CAPLETB-COMPLEX WITH VIT C TABLETB-COMPLEX-VITAMIN C TR TABLETBD SINGLE USE SWABBEKYREE 28 DAY TABLETBENAZEPRIL HCL 10 MG TABLETBENAZEPRIL HCL 20 MG TABLETBENAZEPRIL HCL 40 MG TABLETBENAZEPRIL HCL 5 MG TABLETBENZONATATE 100 MG CAPSULEBENZONATATE 150 MG CAPSULE

F4 11

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

BENZONATATE 200 MG CAPSULEBENZONATATE PERLE 100 MG CAPBENZOYL PEROX 4% CREAMY WASHBENZOYL PEROXIDE 10% GELBENZOYL PEROXIDE 10% LOTIONBENZOYL PEROXIDE 10% WASHBENZOYL PEROXIDE 2.5% GELBENZOYL PEROXIDE 3% CLEANSERBENZOYL PEROXIDE 5% GELBENZOYL PEROXIDE 5% LOTIONBENZOYL PEROXIDE 5% WASHBENZOYL PEROXIDE 5.3% FOAMBENZOYL PEROXIDE 6% CLEANSERBENZOYL PEROXIDE 9% CLEANSERBENZOYL PEROXIDE 9.8% FOAMBETAMETHASONE DP 0.05% CRMBETAMETHASONE DP 0.05% LOTBETAMETHASONE DP 0.05% OINTBETAMETHASONE VA 0.1% CREAMBETAMETHASONE VA 0.1% LOTIONBETAMETHASONE VALER 0.1% OINTMBETAMETHASONE VALER 0.12% FOAMBETASERON 0.3 MG KIT BETASERON 0.3 MG KITBETAXOLOL 10 MG TABLETBETAXOLOL 20 MG TABLETBETAXOLOL HCL 0.5% EYE DROPBETHANECHOL 10 MG TABLETBETHANECHOL 25 MG TABLETBETHANECHOL 5 MG TABLET

F4 12

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

BETHANECHOL 50 MG TABLETBETOPTIC S 0.25% EYE DROPSBICALUTAMIDE 50 MG TABLETBIKTARVY 50-200-25 MG TABLETBISACODYL 10 MG SUPPOSITORYBISACODYL EC 5 MG TABLETBISA-LAX EC 5 MG TABLETBISCOLAX 10 MG SUPPOSITORYBISMATROL 525 MG/15 ML SUSPBISMATROL 525 MG/30 ML SUSPBISMATROL TABLET CHEWBISMUTH 262 MG TABLET CHEWBISMUTH 262 MG/15 ML SUSPBISMUTH 524 MG/30 ML SUSPBLISOVI 24 FE TABLETBLISOVI FE 1.5-30 TABLETBLISOVI FE 1-20 TABLETBP 5% GELBPM-DM-PHEN SYRUPBRAINSTRONG PRENATAL COMBO PACBRIELLYN TABLETBRIMONIDINE 0.2% EYE DROP BRIMONIDINE 0.2% EYE DROP BRIMONIDINE 0.2% EYE DROPBRIMONIDINE TARTRATE 0.15% DRP BRIMONIDINE TARTRATE 0.15% DRPBRIMONIDINE TARTRATE 0.15% DRPBROMFED DM COUGH SYRUPBROMOCRIPTINE 2.5 MG TABLETBROMOCRIPTINE 5 MG CAPSULEBROMPHENIR-PSEUDOEPHED-DM SYRBUDESONIDE 0.25 MG/2 ML SUSPBUDESONIDE 0.5 MG/2 ML SUSP

F4 13

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

BUDESONIDE 1 MG/2 ML INH SUSPBUFFERED ASPIRIN 325 MG TBBUTALB-ACETAMINOPHEN-CAFF 50-3BUTALB-ASPIRIN-CAFFE 50-325-40BUTALBITAL-ACETAMINOPHEN-CAFFEBUTALBITAL-ASA-CAFFEINE CAPBUTISOL SODIUM 30 MG TABLETBUTISOL SODIUM 50 MG TABLETBYETTA 10 MCG DOSE PEN INJ BYETTA 10 MCG DOSE PEN INJ BYETTA 10 MCG DOSE PEN INJBYETTA 5 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJCALCIPOTRIENE 0.005% CREAMCALCIPOTRIENE 0.005% FOAMCALCIPOTRIENE 0.005% OINTMENTCALCIPOTRIENE 0.005% SOLUTIONCALCITONIN-SALMON 200 UNITS SP CALCITONIN-SALMON 200 UNITS SPCALCITONIN-SALMON 200 UNITS SPCALCITRATE + VIT D CAPLETCALCITRIOL 0.25 MCG CAPSULECALCITRIOL 0.5 MCG CAPSULECALCIUM 1,000 + D3 CAPLETCALCIUM 250-D TABLETCALCIUM 250-VIT D3 125 TABLETCALCIUM 500 + VIT D CAPLETCALCIUM 500 MG TABLETCALCIUM 500 MG-VIT D3 600 UNITCALCIUM 500+D TABLET CHEWCALCIUM 500-VIT D3 200 TABLETCALCIUM 500-VIT D3 400 CHEW TBCALCIUM 500-VIT D3 400 TABLETCALCIUM 500-VIT D3 600 TABLET

F4 14

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CALCIUM 600-VIT D3 200 TABLETCALCIUM 600-VIT D3 400 TABLETCALCIUM 600-VIT D3 800 TABLETCALCIUM ACETATE 667 MG CAPSULECALCIUM ACETATE 667 MG TABLETCALCIUM ACETATE 668 MG TABLETCALCIUM CARB 260 MG TAB CHEWCALCIUM CARB 500 (1,250) MG TBCALCIUM CARB 500 MG TAB CHEWCALCIUM CARBONATE 648 MG TABCALCIUM CARBONATE 650 MG TABCALCIUM CARBONATE 750 MG CHEWCALCIUM CARBONATE POWDERCAMILA 0.35 MG TABLETCAPECITABINE 150 MG TABLETCAPECITABINE 500 MG TABLETCAPTOPRIL 12.5 MG TABLETCAPTOPRIL 25 MG TABLETCAPTOPRIL 50 MG TABLETCARAFATE 1 GM/10 ML SUSP CARAFATE 1 GM/10 ML SUSP CARAFATE 1 GM/10 ML SUSPCARBAMOXIDE 6.5% EAR DROPSCARBIDOPA-LEVO 10-100 MG ODTCARBIDOPA-LEVO 25-250 MG ODTCARBIDOPA-LEVO ER 50-200 TABCARBIDOPA-LEVODOPA 10-100 TABCARBIDOPA-LEVODOPA 25-100 TABCARBIDOPA-LEVODOPA 25-250 TABCARB-O-PHILIC 10 CREMECARB-O-PHILIC 20 CREME

F4 15

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CARB-O-PHILIC 40% CREAMCARB-O-PHILIC 40% GELCARRINGTON ANTIFUNGAL 2% CREAMCARTIA XT 120 MG CAPSULECARTIA XT 180 MG CAPSULECARTIA XT 240 MG CAPSULECARTIA XT 300 MG CAPSULECARVEDILOL 12.5 MG TABLETCARVEDILOL 25 MG TABLETCARVEDILOL 3.125 MG TABLETCARVEDILOL 6.25 MG TABLETCAZIANT 28 DAY TABLETCEFACLOR 125 MG/5 ML SUSPCEFACLOR 250 MG CAPSULECEFACLOR 250 MG/5 ML SUSPCEFACLOR 375 MG/5 ML SUSPENCEFACLOR 500 MG CAPSULECEFACLOR ER 500 MG TABLETCEFDINIR 125 MG/5 ML SUSPCEFDINIR 250 MG/5 ML SUSPCEFDINIR 300 MG CAPSULECEFIXIME 100 MG/5 ML SUSPCEFIXIME 200 MG/5 ML SUSPCEFIXIME 400 MG CAPSULECEFPROZIL 125 MG/5 ML SUSPCEFPROZIL 250 MG TABLETCEFPROZIL 250 MG/5 ML SUSPCEFPROZIL 500 MG TABLETCEFTRIAXONE 1 GM ADD-VANT VIAL

F4 16

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CEFTRIAXONE 1 GM VIALCEFTRIAXONE 10 GM VIALCEFTRIAXONE 100 GRAM BULK BAGCEFTRIAXONE 2 GM ADD VIALCEFTRIAXONE 2 GM VIALCEFTRIAXONE 250 MG VIALCEFTRIAXONE 500 MG VIALCEFUROXIME AXETIL 250 MG TABCEFUROXIME AXETIL 500 MG TABCELECOXIB 100 MG CAPSULE CELECOXIB 100 MG CAPSULE CELECOXIB 100 MG CAPSULECELECOXIB 200 MG CAPSULE CELECOXIB 200 MG CAPSULE CELECOXIB 200 MG CAPSULECELECOXIB 400 MG CAPSULE CELECOXIB 400 MG CAPSULE CELECOXIB 400 MG CAPSULECELECOXIB 50 MG CAPSULE CELECOXIB 50 MG CAPSULE CELECOXIB 50 MG CAPSULECEPHALEXIN 125 MG/5 ML SUSPCEPHALEXIN 250 MG CAPSULECEPHALEXIN 250 MG TABLETCEPHALEXIN 250 MG/5 ML SUSPCEPHALEXIN 500 MG CAPSULECEPHALEXIN 500 MG TABLETCEPHALEXIN 750 MG CAPSULECERALYTE-50 POWDER PACKETCERALYTE-70 POWDER PACKETCERALYTE-90 POWDER PACKETCERASPORT EX1 POWDER PACKETCERASPORT POWDERCERASPORT POWDER PACKETCETIRIZINE HCL 1 MG/ML SOLNCETIRIZINE HCL 1 MG/ML SYRUPCETIRIZINE HCL 10 MG CHEW TAB

F4 17

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CETIRIZINE HCL 10 MG TABLETCETIRIZINE HCL 5 MG CHEW TABCETIRIZINE HCL 5 MG TABLETCETIRIZINE HCL 5 MG/5 ML SOLNCHARCOAL 200 MG CAPSULECHARCOAL 260 MG CAPSULECHATEAL EQ-28 TABLETCHATEAL-28 TABLETCHEMET 100 MG CAPSULE CHEMET 100 MG CAPSULECHERATUSSIN AC SYRUPCHEST CONGESTION PLUS DM TABCHEST CONGESTION RELIEF DM TABCHEST CONGST-COUGH RELIEF TABCHILD ACETAMINOPHEN 160 MGCHILD ACETAMINOPHEN 80 MG CHEWCHILD ACETAMINOPHEN 80 MG TABCHILD ACETAMINOPHEN 80 MG/2.5CHILD ALL DAY ALLERGY 1 MG/MLCHILD ALLERGY 5 MG/5 ML SOLNCHILD ALLERGY REL 12.5 MG/5 MLCHILD ALLERGY RELIEF 1 MG/MLCHILD ALLERGY RLF 12.5 MG/5 MLCHILD ASPIRIN 81 MG CHEW TABCHILD ASPIRIN 81 MG TAB CHEWCHILD CETIRIZINE 10 MG CHEW TBCHILD CETIRIZINE 5 MG CHEW TABCHILD CETIRIZINE HCL 1 MG/MLCHILD CHEW + IRON TAB CHEWCHILD CHEW VITAMIN TABLET

F4 18

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CHILD FERROUS SULFATE 15 MG/MLCHILD FEVER REDUCER 120 MG SUPCHILD GLYCERIN SUPPOSITORYCHILD IBUPROFEN 100 MG/5 MLCHILD LORATADINE 10 MG/10 MLCHILD LORATADINE 5 MG/5 ML SOLCHILD LORATADINE 5 MG/5 ML SYRCHILD MUCUS RELIEF COUGH LIQCHILD MUCUS-COUGH RELIEF LIQCHILD MULTIVITAMIN PLUS IRONCHILD MULTIVITAMINS TAB CHEWCHILD NON-ASPIRIN 160 MG/5 MLCHILD PAIN REL-FEVER 120 MG SUCHILD PAIN RLF 160 MG/5 ML LIQCHILD PAIN RLF 160 MG/5 ML SUSCHILD PAIN-FEVER 160 MG TB CHWCHILD PAIN-FEVER 160 MG/5 MLCHILD PAIN-FEVER 80 MG TAB CHWCHILD VITAMIN-IRON TAB CHEWCHILD WAL-ZYR 1 MG/ML SOLUTIONCHILDREN IBUPROFEN 100 MG/5 MLCHILDREN MULTIVITAMIN CHEW TABCHILDREN'S ALLERGY ODTCHILDRENS CHEW VITAMIN TABCHILDREN'S MAPAP 80 MG TAB CHWCHILDREN'S Q-PAP 160 MG/5 MLCHILDREN'S SILAPAP ELIXIRCHILDREN'S WAL-FEX 30 MG/5 MLCHILD'S ALLERGY 12.5 MG/5 ML

F4 19

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CHILD'S ALLER-TEC 1 MG/ML SOLNCHILD'S MAPAP 160 MG TAB CHEWCHILD'S MAPAP 160 MG/5 ML LIQCHILD'S PAIN RELIEVER RAPID TBCHILD'S PAIN RELIEVER SUSPCHILD'S WAL-DRYL 12.5 MG/5 MLCHILD'S WAL-DRYL ALLERGY ODTCHILD'S WAL-ZYR 10 MG CHEW TABCHL ACETAMINOPHEN 325 MG/10.15CHLD ACETAMINOPHEN 160 MG/5 MLCHLD ALLRGY RLF 12.5 MG CHEW TCHLORHEXIDINE 0.12% RINSECHLOROQUINE PH 250 MG TABLETCHLOROQUINE PH 500 MG TABLETCHLOROTHIAZIDE 250 MG TABLETCHLOROTHIAZIDE 500 MG TABLETCHLORPHENIRAMINE 4 MG TABLETCHLORPHENIRAMINE ER 12 MG TABCHLORTHALIDONE 25 MG TABLETCHLORTHALIDONE 50 MG TABLETCHOLESTYRAMINE LIGHT PACKETCHOLESTYRAMINE LIGHT POWDERCHOLINE MAG TRISAL LIQUIDCILOSTAZOL 100 MG TABLETCILOSTAZOL 50 MG TABLETCILOXAN 0.3% OINTMENTCIPROFLOXACIN 0.2% OTIC SOLNCIPROFLOXACIN 0.3% EYE DROPCIPROFLOXACIN 250 MG/5 ML SUSP

F4 20

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CIPROFLOXACIN 500 MG/5 ML SUSPCIPROFLOXACIN HCL 100 MG TABCIPROFLOXACIN HCL 250 MG TABCIPROFLOXACIN HCL 500 MG TABCIPROFLOXACIN HCL 750 MG TABCITRANATAL 90 DHA COMBO PACKCITRANATAL ASSURE COMBO PACKCITRANATAL DHA PACKCITRANATAL HARMONY CAPSULECITRANATAL RX TABLETCLARITHROMYCIN 125 MG/5 ML SUSCLARITHROMYCIN 250 MG TABLETCLARITHROMYCIN 250 MG/5 ML SUSCLARITHROMYCIN 500 MG TABLETCLARITHROMYCIN ER 500 MG TABCLASSIC PRENATAL TABLETCLEMASTINE 0.5 MG/5 ML SYRUPCLEMASTINE FUM 1.34 MG TABLETCLEMASTINE FUM 2.68 MG TABCLINDAMYCIN 2% VAGINAL CREAMCLINDAMYCIN 75 MG/5 ML SOLNCLINDAMYCIN HCL 150 MG CAPSULECLINDAMYCIN HCL 300 MG CAPSULECLINDAMYCIN HCL 75 MG CAPSULECLINDAMYCIN PEDIATR 75 MG/5 MLCLINDAMYCIN PEDIATRIC 75 MG/5CLINDAMYCIN PH 1% GELCLINDAMYCIN PH 1% SOLUTIONCLINDAMYCIN PHOS 1% PLEDGET

F4 21

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CLINDAMYCIN PHOSP 1% LOTIONCLINDAMYCIN PHOSPHATE 1% FOAMCLINDAMYCIN PHOSPHATE 1% GELCLOBETASOL 0.05% CREAMCLOBETASOL 0.05% GELCLOBETASOL 0.05% OINTMENTCLOBETASOL 0.05% SHAMPOOCLOBETASOL 0.05% SOLUTIONCLOBETASOL 0.05% TOPICAL LOTNCLOBETASOL EMOLLIENT 0.05% CRMCLOBETASOL PROP 0.05% FOAMCLOBETASOL PROP 0.05% SPRAYCLONIDINE HCL 0.1 MG TABLETCLONIDINE HCL 0.2 MG TABLETCLONIDINE HCL 0.3 MG TABLETCLOPIDOGREL 300 MG TABLETCLOPIDOGREL 75 MG TABLETCLORPRES 0.1-15 TABLETCLORPRES 0.2-15 TABLETCLORPRES 0.3-15 TABLETCLOTRIMAZOLE 1% CREAMCLOTRIMAZOLE 1% TOP CREAM GRXCLOTRIMAZOLE 1% TOPICAL CREAMCLOTRIMAZOLE 1% VAGINAL CREAMCLOTRIMAZOLE 10 MG TROCHECLOTRIMAZOLE 3 DAY CREAMCLOTRIMAZOLE-3 2% CREAMCLOTRIMAZOLE-7 VAGINAL CREAMC-NATE DHA SOFTGEL

F4 22

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CODEINE SULFATE 15 MG TABLETCODEINE SULFATE 15 MG/2.5 MLCODEINE SULFATE 30 MG TABLETCODEINE SULFATE 30 MG/5 ML SOLCODEINE SULFATE 60 MG TABLETCODEINE-GUAIFEN 10-100 MG/5 MLCOLCHICINE 0.6 MG CAPSULECOLCHICINE 0.6 MG TABLETCOLESTIPOL HCL 1 GM TABLETCOLESTIPOL HCL GRANULESCOLESTIPOL HCL GRANULES PACKETCOLESTIPOL MICRONIZED 1 GM TABCOL-RITE 250 MG SOFTGELCOMBIVENT RESPIMAT 20-100 MCGCOMPLERA TABLETCOMPLETE MULTI 50+ TABLETCOMPLETE MULTI TABLETCOMPLETE MULTIVITAMIN TABCOMPLETE NATAL DHACOMPLETENATE TABLET CHEWCONDOMS LUBRICATEDCONDYLOX 0.5% GELCONSTULOSE 10 GM/15 ML SOLNCONTOUR METERCONTOUR NEXT EZ METERCONTOUR NEXT METERCONTOUR NEXT TEST STRIPCONTOUR TEST STRIPCOPAXONE 20 MG/ML SYRINGE COPAXONE 20 MG/ML SYRINGE

F4 23

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

COPAXONE 40 MG/ML SYRINGE COPAXONE 40 MG/ML SYRINGECORTISONE 25 MG TABLETCORTISPORIN CREAMCORTISPORIN OINTMENTCOUGH DM SYRUPCOUGH SYRUPCOUGH SYRUP DMCOUGH-CHEST CONGESTION DM LIQCREON DR 12,000 UNITS CAPSULECREON DR 24,000 UNITS CAPSULECREON DR 3,000 UNITS CAPSULECREON DR 36,000 UNITS CAPSULECREON DR 6,000 UNITS CAPSULECROMOLYN 20 MG/2 ML NEB SOLNCROMOLYN SODIUM NASAL SOLUTIONCROMOLYN SODIUM NASAL SPRAYCRYSELLE-28 TABLETCUPRIMINE 250 MG CAPSULECYANOCOBALAMIN 1,000 MCG/ML CYANOCOBALAMIN 1,000 MCG/MLCYANOCOBALAMIN 10,000 MCG/10 CYANOCOBALAMIN 10,000 MCG/10CYANOCOBALAMIN 30,000 MCG/30 CYANOCOBALAMIN 30,000 MCG/30CYCLAFEM 1-35-28 TABLETCYCLAFEM 7-7-7-28 TABLETCYCLOBENZAPRINE 10 MG TABLETCYCLOBENZAPRINE 5 MG TABLETCYCLOBENZAPRINE 7.5 MG TABLETCYCLOPHOSPHAMIDE 1 GM VIALCYCLOPHOSPHAMIDE 2 GM VIALCYCLOPHOSPHAMIDE 25 MG CAPSULE

F4 24

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

CYCLOPHOSPHAMIDE 50 MG CAPSULECYCLOPHOSPHAMIDE 500 MG VIALCYCLOSERINE 250 MG CAPSULECYCLOSPORINE 100 MG CAPSULECYCLOSPORINE 25 MG CAPSULECYCLOSPORINE MODIFIED 100 MGCYCLOSPORINE MODIFIED 100 MG/MCYCLOSPORINE MODIFIED 25 MGCYCLOSPORINE MODIFIED 50 MGCYRED 28 DAY TABLETCYRED EQ 28 DAY TABLETD3-50 50,000 UNIT CAPSULEDANAZOL 100 MG CAPSULEDANAZOL 200 MG CAPSULEDANAZOL 50 MG CAPSULEDANTROLENE SODIUM 100 MG CAP DANTROLENE SODIUM 100 MG CAPDANTROLENE SODIUM 100 MG CAPDANTROLENE SODIUM 20 MG VIAL DANTROLENE SODIUM 20 MG VIALDANTROLENE SODIUM 20 MG VIALDANTROLENE SODIUM 25 MG CAP DANTROLENE SODIUM 25 MG CAPDANTROLENE SODIUM 25 MG CAPDANTROLENE SODIUM 50 MG CAP DANTROLENE SODIUM 50 MG CAPDANTROLENE SODIUM 50 MG CAPDAPSONE 100 MG TABLETDAPSONE 25 MG TABLETDAPSONE 5% GELDAPSONE 7.5% GEL PUMPDARAPRIM 25 MG TABLETDASETTA 1-35-28 TABLETDASETTA 7/7/7-28 TABLETDAYSEE 0.15-0.03-0.01 MG TABDEBLITANE 0.35 MG TABLETDELYLA-28 TABLET

F4 25

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DEPO-PROVERA 150 MG/ML SYRINGEDEPO-PROVERA 150 MG/ML VIALDEPO-PROVERA 400 MG/ML VIALDEPO-SUBQ PROVERA 104 SYRINGEDESCOVY 200-25 MG TABLETDESMOPRESSIN 0.01% SOLUTION DESMOPRESSIN 0.01% SOLUTIONDESMOPRESSIN 0.01% SPRAY DESMOPRESSIN 0.01% SPRAYDESMOPRESSIN 0.1 MG/ML SOL DESMOPRESSIN 0.1 MG/ML SOLDESMOPRESSIN 0.1 MG/ML SPRAY DESMOPRESSIN 0.1 MG/ML SPRAYDESMOPRESSIN 10 MCG/0.1 ML SPR DESMOPRESSIN 10 MCG/0.1 ML SPRDESMOPRESSIN 40 MCG/10 ML VIAL DESMOPRESSIN 40 MCG/10 ML VIALDESMOPRESSIN AC 4 MCG/ML AMPUL DESMOPRESSIN AC 4 MCG/ML AMPULDESMOPRESSIN AC 4 MCG/ML VIAL DESMOPRESSIN AC 4 MCG/ML VIALDESMOPRESSIN ACETATE 0.1 MG TB DESMOPRESSIN ACETATE 0.1 MG TBDESMOPRESSIN ACETATE 0.2 MG TB DESMOPRESSIN ACETATE 0.2 MG TBDESOGEST-ETH ESTRA 0.15-0.03 MDESOGESTREL-ETHINYL ESTRAD TABDESOGESTR-ETH ESTRAD ETH ESTRADESONIDE 0.05% CREAMDESONIDE 0.05% LOTIONDESONIDE 0.05% OINTMENTDEXAMETHASONE 0.1% EYE DROPDEXAMETHASONE 0.5 MG TABLETDEXAMETHASONE 0.5 MG/5 ML ELXDEXAMETHASONE 0.5 MG/5 ML LIQDEXAMETHASONE 0.75 MG TABLETDEXAMETHASONE 1 MG TABLETDEXAMETHASONE 1.5 MG TABLETDEXAMETHASONE 10 DAY 1.5 MG TB

F4 26

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DEXAMETHASONE 10 MG/ML VIALDEXAMETHASONE 100 MG/10 ML VLDEXAMETHASONE 120 MG/30 ML VLDEXAMETHASONE 13 DAY 1.5 MG TBDEXAMETHASONE 2 MG TABLETDEXAMETHASONE 20 MG/5 ML VIALDEXAMETHASONE 4 MG TABLETDEXAMETHASONE 4 MG/ML SYRINGEDEXAMETHASONE 4 MG/ML VIALDEXAMETHASONE 6 DAY 1.5 MG TABDEXAMETHASONE 6 MG TABLETDIABETIC SILTUSSIN-DM LIQUIDDIABETIC SILTUSSIN-DM MAX-STRDIABETIC TUSSIN DM LIQUIDDIABETIC TUSSIN DM MAX-STR LIQDIARRHEA RELIEF 262 MG/15 MLDIARRHEA RELIEF SUSPENSIONDICLOFENAC 0.1% EYE DROPSDICLOFENAC POT 50 MG TABLETDICLOFENAC SOD DR 25 MG TABDICLOFENAC SOD DR 50 MG TABDICLOFENAC SOD DR 75 MG TABDICLOFENAC SOD EC 25 MG TABDICLOFENAC SOD EC 50 MG TABDICLOFENAC SOD EC 75 MG TABDICLOFENAC SODIUM 1% GELDICLOXACILLIN 250 MG CAPSULEDICLOXACILLIN 500 MG CAPSULEDICYCLOMINE 10 MG CAPSULE

F4 27

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DICYCLOMINE 10 MG/5 ML SOLNDICYCLOMINE 20 MG TABLETDICYCLOMINE 20 MG/2 ML AMPULDICYCLOMINE 20 MG/2 ML VIALDIGITEK 125 MCG TABLETDIGITEK 250 MCG TABLETDIGOX 125 MCG TABLETDIGOX 250 MCG TABLETDIGOXIN 0.05 MG/ML SOLUTIONDIGOXIN 0.125 MG TABLETDIGOXIN 0.125 MG/2.5 ML SOLNDIGOXIN 0.25 MG TABLETDIGOXIN 0.25 MG/5 ML SOLUTIONDIGOXIN 0.25 MG/ML SYRINGEDIGOXIN 125 MCG TABLETDIGOXIN 250 MCG TABLETDIGOXIN 500 MCG/2 ML AMPULEDILANTIN 30 MG CAPSULEDILT XR 120 MG CAPSULEDILT XR 180 MG CAPSULEDILT XR 240 MG CAPSULEDILTIAZEM 100 MG ADD-VAN VIALDILTIAZEM 120 MG TABLETDILTIAZEM 125 MG/25 ML VIALDILTIAZEM 12HR ER 120 MG CAPDILTIAZEM 12HR ER 60 MG CAPDILTIAZEM 12HR ER 90 MG CAPDILTIAZEM 24H ER(CD) 120 MG CPDILTIAZEM 24H ER(CD) 180 MG CP

F4 28

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DILTIAZEM 24H ER(CD) 240 MG CPDILTIAZEM 24H ER(CD) 300 MG CPDILTIAZEM 24H ER(CD) 360 MG CPDILTIAZEM 24H ER(LA) 180 MG TBDILTIAZEM 24H ER(LA) 240 MG TBDILTIAZEM 24H ER(LA) 300 MG TBDILTIAZEM 24H ER(LA) 360 MG TBDILTIAZEM 24H ER(LA) 420 MG TBDILTIAZEM 24H ER(XR) 120 MG CPDILTIAZEM 24H ER(XR) 180 MG CPDILTIAZEM 24H ER(XR) 240 MG CPDILTIAZEM 24HR ER 120 MG CAPDILTIAZEM 24HR ER 180 MG CAPDILTIAZEM 24HR ER 240 MG CAPDILTIAZEM 24HR ER 300 MG CAPDILTIAZEM 24HR ER 360 MG CAPDILTIAZEM 24HR ER 420 MG CAPDILTIAZEM 25 MG/5 ML VIALDILTIAZEM 30 MG TABLETDILTIAZEM 50 MG/10 ML VIALDILTIAZEM 60 MG TABLETDILTIAZEM 90 MG TABLETDIPHEDRYL 12.5 MG/5 ML ELIXIRDIPHEDRYL 25 MG TABLETDIPHEDRYL ALLERGY CAPSULEDIPHENHYDRAMINE 12.5 MG/5 MLDIPHENHYDRAMINE 25 MG CAPLETDIPHENHYDRAMINE 25 MG CAPSULEDIPHENHYDRAMINE 25 MG TABLET

F4 29

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DIPHENHYDRAMINE 25 MG/10 MLDIPHENHYDRAMINE 50 MG CAPSULEDIPHENHYDRAMINE 50 MG TABLETDIPHENHYDRAMINE 50 MG/ML CRPJTDIPHENHYDRAMINE 50 MG/ML SYRNGDIPHENHYDRAMINE 50 MG/ML VIALDIPHENHYDRAMINE 6.25 MG/ML DRPDIPHENHYDRAMINE COUGH SYRUPDIPHENOXYLATE-ATROPINE 2.5-0.0DIPYRIDAMOLE 25 MG TABLETDIPYRIDAMOLE 5 MG/ML VIALDIPYRIDAMOLE 50 MG TABLETDIPYRIDAMOLE 75 MG TABLETDISOPYRAMIDE 100 MG CAPSULEDISOPYRAMIDE 150 MG CAPSULEDIURIL 250 MG/5 ML ORAL SUSPDM-GUAIF-PE 17.5-385-10 MG TABDM-GUAIF-PE 18-200-10 MG/15 MLDOC-Q-LACE 100 MG SOFTGELDOCUSATE CAL 240 MG CAPSULEDOCUSATE CAL 240 MG SOFTGELDOCUSATE SOD 20 MG/5 ML SYRUPDOCUSATE SOD 60 MG/15 ML SYRPDOCUSATE SODIUM 100 MG CAPSULEDOCUSATE SODIUM 100 MG SOFTGELDOCUSATE SODIUM 100 MG TABLETDOCUSATE SODIUM 250 MG CAPSULEDOCUSATE SODIUM 250 MG SOFTGELDOCUSATE SODIUM 50 MG/5 ML LIQ

F4 30

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DOCUSATE SODIUM MINI ENEMADOCUSATE SODIUM-SENNA TABLETDOCUSIL 100 MG SOFTGELDOK 100 MG TABLETDONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL 10 MG TABLETDONEPEZIL HCL 23 MG TABLET DONEPEZIL HCL 23 MG TABLETDONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL 5 MG TABLETDONEPEZIL HCL ODT 10 MG TABLET DONEPEZIL HCL ODT 10 MG TABLETDONEPEZIL HCL ODT 5 MG TABLET DONEPEZIL HCL ODT 5 MG TABLETDORZOLAMIDE HCL 2% EYE DROPSDORZOLAMIDE-TIMOLOL EYE DROPSDOXAZOSIN MESYLATE 1 MG TABDOXAZOSIN MESYLATE 2 MG TABDOXAZOSIN MESYLATE 4 MG TABDOXAZOSIN MESYLATE 8 MG TABDOXYCYCLINE 25 MG/5 ML SUSPDOXYCYCLINE 50 MG TABLETDOXYCYCLINE HYC DR 100 MG TABDOXYCYCLINE HYC DR 150 MG TABDOXYCYCLINE HYC DR 200 MG TABDOXYCYCLINE HYC DR 50 MG TABDOXYCYCLINE HYC DR 75 MG TABDOXYCYCLINE HYC DR 80 MG TABDOXYCYCLINE HYCLATE 100 MG CAPDOXYCYCLINE HYCLATE 100 MG TABDOXYCYCLINE HYCLATE 100 MG VLDOXYCYCLINE HYCLATE 150 MG TABDOXYCYCLINE HYCLATE 20 MG TABDOXYCYCLINE HYCLATE 50 MG CAP

F4 31

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

DOXYCYCLINE HYCLATE 75 MG TABDOXYCYCLINE IR-DR 40 MG CAPDOXYCYCLINE MONO 100 MG CAPDOXYCYCLINE MONO 100 MG TABLETDOXYCYCLINE MONO 150 MG CAPDOXYCYCLINE MONO 150 MG TABLETDOXYCYCLINE MONO 50 MG CAPDOXYCYCLINE MONO 50 MG TABLETDOXYCYCLINE MONO 75 MG CAPSULEDOXYCYCLINE MONO 75 MG TABLETDROSP-EE-LEVOMEF 3-0.02-0.451DROSP-EE-LEVOMEF 3-0.03-0.451DROSPIRENONE-EE 3-0.02 MG TABDROSPIRENONE-EE 3-0.03 MG TABDUREX AVANTI REAL FEEL CONDOME.E.S. 200 MG/5 ML GRANULESE.E.S. 200 MG/5 ML SUSPENSIONE.E.S. 400 FILMTABEAR DROPS 6.5%EAR SYSTEM 6.5%EAR WAX REMOVAL 6.5% DROPEAR WAX REMOVAL 6.5% DROPSEAR WAX REMOVAL 6.5% KITECPIRIN EC 325 MG TABLETEFAVIRENZ 200 MG CAPSULEEFAVIRENZ 50 MG CAPSULEEFAVIRENZ 600 MG TABLETELECTROLYTE SOLUTIONELIDEL 1% CREAM ELIDEL 1% CREAM ELIDEL 1% CREAM

F4 32

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ELINEST-28 TABLETELIQUIS 2.5 MG TABLETELIQUIS 5 MG TABLETELIQUIS DVT-PE TREATMENT 30-DAEMEND 125 MG POWDER PACKET EMEND 125 MG POWDER PACKETEMOQUETTE 28 DAY TABLETENABLEX 15 MG TABLET ENABLEX 15 MG TABLET ENABLEX 15 MG TABLETENABLEX 7.5 MG TABLET ENABLEX 7.5 MG TABLET ENABLEX 7.5 MG TABLETENALAPRIL MALEATE 10 MG TABENALAPRIL MALEATE 2.5 MG TABENALAPRIL MALEATE 20 MG TABENALAPRIL MALEATE 5 MG TABLETENBRACE HR SOFTGELENBREL 25 MG KIT ENBREL 25 MG KIT ENBREL 25 MG KITENBREL 25 MG/0.5 ML SYRINGE ENBREL 25 MG/0.5 ML SYRINGEENBREL 25 MG/0.5 ML SYRINGEENBREL 50 MG/ML MINI CARTRIDGE ENBREL 50 MG/ML MINI CARTRIDGEENBREL 50 MG/ML MINI CARTRIDGEENBREL 50 MG/ML SURECLICK ENBREL 50 MG/ML SURECLICK ENBREL 50 MG/ML SURECLICKENBREL 50 MG/ML SYRINGE ENBREL 50 MG/ML SYRINGE ENBREL 50 MG/ML SYRINGEENDOCET 2.5-325 MG TABLETENDOCET 5-325 TABLETENDOCET 7.5-325 MG TABLETENEMAENFAMIL ENFACARE LIQUIDENFAMIL ENFALYTE SOLUTIONENFAMIL GENTLEASE NON-GMO POWDENFAMIL INFANT LIQUIDENFAMIL INFANT POWDERENFAMIL NEWBORN LIQUIDENFAMIL PREMATR LOW IRON 20 LQ

F4 33

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ENFAMIL PROSOBEE LIPIL LIQENFAMIL REGULINE LIQUIDENOXAPARIN 100 MG/ML SYRINGEENOXAPARIN 120 MG/0.8 ML SYRENOXAPARIN 150 MG/ML SYRINGEENOXAPARIN 30 MG/0.3 ML SYRENOXAPARIN 300 MG/3 ML VIALENOXAPARIN 40 MG/0.4 ML SYRENOXAPARIN 60 MG/0.6 ML SYRENOXAPARIN 80 MG/0.8 ML SYRENPRESSE-28 TABLETENSKYCE 28 TABLETENSURE LIQUID ENSURE LIQUIDENSURE POWDER ENSURE POWDERENTRESTO 24 MG-26 MG TABLETENTRESTO 49 MG-51 MG TABLETENTRESTO 97 MG-103 MG TABLETENULOSE 10 GM/15 ML SOLUTIONEPINEPHRINE 0.15 MG AUTO-INJCTEPINEPHRINE 0.3 MG AUTO-INJECTEPIPEN 2-PAK 0.3 MG AUTO-INJCTEPIPEN JR 2-PAK 0.15 MG INJCTREPOGEN 10,000 UNITS/ML VIAL EPOGEN 10,000 UNITS/ML VIALEPOGEN 2,000 UNITS/ML VIAL EPOGEN 2,000 UNITS/ML VIALEPOGEN 20,000 UNITS/2 ML VIAL EPOGEN 20,000 UNITS/2 ML VIALEPOGEN 20,000 UNITS/ML VIAL EPOGEN 20,000 UNITS/ML VIALEPOGEN 3,000 UNITS/ML VIAL EPOGEN 3,000 UNITS/ML VIALEPOGEN 4,000 UNITS/ML VIAL EPOGEN 4,000 UNITS/ML VIALERGOLOID MESYLATES 1 MG TAB

F4 34

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ERRIN 0.35 MG TABLETERYPED 200 MG/5 ML SUSPENSIONERY-TAB DR 250 MG TABLETERY-TAB DR 333 MG TABLETERY-TAB DR 500 MG TABLETERYTHROCIN 1 GM ADDVANT VIALERYTHROCIN 250 MG FILMTABERYTHROCIN 500 MG ADDVAN VIALERYTHROCIN LACT 500 MG VIALERYTHROMYCIN 0.5% EYE OINTMENTERYTHROMYCIN 2% GELERYTHROMYCIN 200 MG/5 ML SUSPERYTHROMYCIN 250 MG FILMTABERYTHROMYCIN 400 MG/5 ML SUSPERYTHROMYCIN 500 MG FILMTABERYTHROMYCIN DR 250 MG CAPERYTHROMYCIN DR 250 MG TABLETERYTHROMYCIN DR 333 MG TABLETERYTHROMYCIN DR 500 MG TABLETERYTHROMYCIN ES 400 MG TABESCAVITE D TABLET CHEWABLEESCAVITE LQ DROPSESCAVITE TABLET CHEWABLEESSENTIAL MAN 50+ TABLETESSENTIAL MAN TABLETESSENTIAL WOMAN 50+ TABLETESTARYLLA 0.25 MG-0.035 MG TABESTARYLLA 0.25-0.035 MG TABLETESTRACE 0.01% CREAM

F4 35

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ESTRACE 0.5 MG TABLETESTRACE 1 MG TABLETESTRACE 2 MG TABLETESTRADIOL 0.01% CREAMESTRADIOL 0.025 MG PATCHESTRADIOL 0.0375 MG PATCHESTRADIOL 0.0375 MG/DAY PATCHESTRADIOL 0.05 MG PATCHESTRADIOL 0.06 MG/DAY PATCHESTRADIOL 0.075 MG PATCHESTRADIOL 0.075 MG/DAY PATCHESTRADIOL 0.1 MG PATCHESTRADIOL 0.5 MG TABLETESTRADIOL 1 MG TABLETESTRADIOL 2 MG TABLETESTRADIOL TDS 0.025 MG/DAYESTRADIOL TDS 0.0375 MG/DAYESTRADIOL TDS 0.05 MG/DAYESTRADIOL TDS 0.06 MG/DAYESTRADIOL TDS 0.075 MG/DAYESTRADIOL TDS 0.1 MG/DAYETHAMBUTOL HCL 100 MG TABLETETHAMBUTOL HCL 400 MG TABLETETHOSUXIMIDE 250 MG CAPSULEETHOSUXIMIDE 250 MG/5 ML SOLNETHYNODIOL-ETH ESTRA 1 MG-35 METHYNODIOL-ETH ESTRA 1 MG-50 METODOLAC 200 MG CAPSULEETODOLAC 300 MG CAPSULE

F4 36

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ETODOLAC 400 MG TABLETETODOLAC 500 MG TABLETETODOLAC ER 400 MG TABLETETODOLAC ER 500 MG TABLETETODOLAC ER 600 MG TABLETETOPOSIDE 1,000 MG/50 ML VIALETOPOSIDE 100 MG/5 ML VIALETOPOSIDE 50 MG CAPSULEETOPOSIDE 500 MG/25 ML VIALEVOTAZ 300 MG-150 MG TABLETEXELON 13.3 MG/24HR PATCH EXELON 13.3 MG/24HR PATCHEXELON 9.5 MG/24HR PATCH EXELON 9.5 MG/24HR PATCHEXEMESTANE 25 MG TABLETEXTRA ACTION COUGH SYRUPEYE ITCH RELIEF 0.025% DROPSEYE VITAMIN-MINERALS TABLETFALMINA-28 TABLETFAMOTIDINE 10 MG TABLETFAMOTIDINE 20 MG TABLETFAMOTIDINE 200 MG/20 ML VIALFAMOTIDINE 40 MG TABLETFANTASY CONDOMFAYOSIM TABLETFC2 FEMALE CONDOMFEIBA NF 1,000 UNIT (NOMINAL) FEIBA NF 1,000 UNIT (NOMINAL)FEIBA NF 1,750-3,250 UNIT VIAL FEIBA NF 1,750-3,250 UNIT VIALFEIBA NF 2,500 UNIT (NOMINAL) FEIBA NF 2,500 UNIT (NOMINAL)FEIBA NF 400-650 UNIT VIAL FEIBA NF 400-650 UNIT VIALFEIBA NF 500 UNIT (NOMINAL) FEIBA NF 500 UNIT (NOMINAL)

F4 37

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

FEIBA NF 651-1,200 UNIT VIAL FEIBA NF 651-1,200 UNIT VIALFELODIPINE ER 10 MG TABLETFELODIPINE ER 2.5 MG TABLETFELODIPINE ER 5 MG TABLETFEMYNOR 28 TABLETFENOFIBRATE 130 MG CAPSULE FENOFIBRATE 130 MG CAPSULEFENOFIBRATE 130 MG CAPSULEFENOFIBRATE 134 MG CAPSULE FENOFIBRATE 134 MG CAPSULEFENOFIBRATE 134 MG CAPSULEFENOFIBRATE 150 MG CAPSULEFENOFIBRATE 160 MG TABLETFENOFIBRATE 200 MG CAPSULE FENOFIBRATE 200 MG CAPSULEFENOFIBRATE 200 MG CAPSULEFENOFIBRATE 40 MG TABLETFENOFIBRATE 43 MG CAPSULE FENOFIBRATE 43 MG CAPSULE FENOFIBRATE 43 MG CAPSULEFENOFIBRATE 50 MG CAPSULEFENOFIBRATE 54 MG TABLETFENOFIBRATE 67 MG CAPSULE FENOFIBRATE 67 MG CAPSULE FENOFIBRATE 67 MG CAPSULEFENOFIBRIC ACID 105 MG TABLET FENOFIBRIC ACID 105 MG TABLETFENOFIBRIC ACID 105 MG TABLETFENOFIBRIC ACID 35 MG TABLET FENOFIBRIC ACID 35 MG TABLETFENOFIBRIC ACID 35 MG TABLETFENOFIBRIC ACID DR 135 MG CAP FENOFIBRIC ACID DR 135 MG CAPFENOFIBRIC ACID DR 135 MG CAPFENOFIBRIC ACID DR 45 MG CAP FENOFIBRIC ACID DR 45 MG CAPFENOFIBRIC ACID DR 45 MG CAPFENOPROFEN 200 MG CAPSULEFENOPROFEN 400 MG CAPSULEFENOPROFEN 600 MG TABLETFENOPROFEN CALCIUM 400 MG CAPFENTANYL 100 MCG/HR PATCH FENTANYL 100 MCG/HR PATCH FENTANYL 100 MCG/HR PATCHFENTANYL 12 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH FENTANYL 12 MCG/HR PATCHFENTANYL 25 MCG/HR PATCH FENTANYL 25 MCG/HR PATCH FENTANYL 25 MCG/HR PATCHFENTANYL 37.5 MCG/HR PATCH FENTANYL 37.5 MCG/HR PATCHFENTANYL 37.5 MCG/HR PATCHFENTANYL 50 MCG/HR PATCH FENTANYL 50 MCG/HR PATCH FENTANYL 50 MCG/HR PATCHFENTANYL 62.5 MCG/HR PATCH FENTANYL 62.5 MCG/HR PATCHFENTANYL 62.5 MCG/HR PATCH

F4 38

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

FENTANYL 75 MCG/HR PATCH FENTANYL 75 MCG/HR PATCH FENTANYL 75 MCG/HR PATCHFENTANYL 87.5 MCG/HR PATCH FENTANYL 87.5 MCG/HR PATCHFENTANYL 87.5 MCG/HR PATCHFERRO-TIME 325 MG TABLETFERROUS GLUCONATE 240 MG TABFERROUS GLUCONATE 324 MG TABFERROUS SUL 12.5 MG (IRON)/0.8FERROUS SULF 15 MG (IRON)/ML OFERROUS SULF 15 MG IRON/ML DRPFERROUS SULF 220 MG/5 ML ELIXFERROUS SULF 220 MG/5 ML LIQFERROUS SULF 300 MG/5 ML LIQFERROUS SULF 44 MG IRON/5 ML LFERROUS SULF EC 324 MG TABLETFERROUS SULF EC 325 MG TABLETFERROUS SULFATE 325 MG TABLETFERROUS SULFATE ER 140 MG TABFERROUSUL 325 MG TABLETFEXOFENADINE HCL 180 MG TABLETFEXOFENADINE HCL 30 MG/5 MLFEXOFENADINE-PSE ER 60-120 TABFIBER TABLETFIBER THERAPY POWDERFIBRICOR 105 MG TABLET FIBRICOR 105 MG TABLET FIBRICOR 105 MG TABLETFIBRICOR 35 MG TABLET FIBRICOR 35 MG TABLET FIBRICOR 35 MG TABLETFIFTY50 ALCOHOL PREP PADSFINASTERIDE 1 MG TABLETFINASTERIDE 5 MG TABLETFIRST AID BACITRACIN OINTMENTFLAVOXATE HCL 100 MG TABLET

F4 39

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

FLECAINIDE ACETATE 100 MG TABFLECAINIDE ACETATE 150 MG TABFLECAINIDE ACETATE 50 MG TABFLEET ENEMAFLEET PEDIA-LAX ENEMAFLORIVA PLUS 0.25 MG/ML DROPFLORIVA PLUS 0.25 MG/ML DROPSFLOVENT HFA 110 MCG INHALERFLOVENT HFA 220 MCG INHALERFLOVENT HFA 44 MCG INHALERFLUCONAZOLE 10 MG/ML SUSP FLUCONAZOLE 10 MG/ML SUSPFLUCONAZOLE 10 MG/ML SUSPFLUCONAZOLE 100 MG TABLET FLUCONAZOLE 100 MG TABLET FLUCONAZOLE 100 MG TABLETFLUCONAZOLE 150 MG TABLETFLUCONAZOLE 200 MG TABLET FLUCONAZOLE 200 MG TABLET FLUCONAZOLE 200 MG TABLETFLUCONAZOLE 40 MG/ML SUSP FLUCONAZOLE 40 MG/ML SUSPFLUCONAZOLE 40 MG/ML SUSPFLUCONAZOLE 50 MG TABLET FLUCONAZOLE 50 MG TABLET FLUCONAZOLE 50 MG TABLETFLUDROCORTISONE 0.1 MG TABLETFLUNISOLIDE 0.025% SPRAYFLUOCINOLONE 0.01% CREAMFLUOCINOLONE 0.01% SOLUTIONFLUOCINOLONE 0.025% CREAMFLUOCINOLONE 0.025% OINTMENTFLUOCINONIDE 0.05% CREAMFLUOCINONIDE 0.05% GELFLUOCINONIDE 0.05% OINTMENTFLUOCINONIDE 0.05% SOLUTIONFLUOCINONIDE 0.1% CREAMFLUORIDE 0.25 MG TABLET CHEWFLUORIDE 0.5 MG TABLET CHEW

F4 40

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

FLUORIDE 1 MG TABLET CHEWABLEFLUOROURACIL 0.5% CREAMFLUOROURACIL 5% CREAMFLURBIPROFEN 0.03% EYE DROPFLURBIPROFEN 100 MG TABLETFLURBIPROFEN 50 MG TABLETFLUTAMIDE 125 MG CAPSULEFLUTICASONE PROP 50 MCG SPRAYFLUTICASONE-SALMETEROL 100-50 FLUTICASONE-SALMETEROL 100-50FLUTICASONE-SALMETEROL 100-50FLUTICASONE-SALMETEROL 113-14 FLUTICASONE-SALMETEROL 113-14FLUTICASONE-SALMETEROL 113-14FLUTICASONE-SALMETEROL 232-14 FLUTICASONE-SALMETEROL 232-14FLUTICASONE-SALMETEROL 232-14FLUTICASONE-SALMETEROL 250-50 FLUTICASONE-SALMETEROL 250-50FLUTICASONE-SALMETEROL 250-50FLUTICASONE-SALMETEROL 500-50 FLUTICASONE-SALMETEROL 500-50FLUTICASONE-SALMETEROL 500-50FLUTICASONE-SALMETEROL 55-14 FLUTICASONE-SALMETEROL 55-14FLUTICASONE-SALMETEROL 55-14FLUVASTATIN ER 80 MG TABLETFLUVASTATIN SODIUM 20 MG CAPFLUVASTATIN SODIUM 40 MG CAPFOLIC ACID 1 MG TABLETFOLIC ACID 1,000 MCG TABLETFOLIC ACID 20 MG CAPSULEFOLIC ACID-VIT B6-VIT B12 TABFORTEO 600 MCG/2.4 ML PEN INJFOSAMAX PLUS D 70 MG-2,800 UNIFOSAMAX PLUS D 70 MG-5,600 UNIFOSAMPRENAVIR 700 MG TABLETFOSINOPRIL SODIUM 10 MG TABFOSINOPRIL SODIUM 20 MG TABFOSINOPRIL SODIUM 40 MG TABFUROSEMIDE 10 MG/ML SOLUTION

F4 41

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

FUROSEMIDE 10 MG/ML VIALFUROSEMIDE 100 MG/10 ML SYRINGFUROSEMIDE 100 MG/10 ML VIALFUROSEMIDE 20 MG TABLETFUROSEMIDE 20 MG/2 ML VIALFUROSEMIDE 40 MG TABLETFUROSEMIDE 40 MG/4 ML ORAL SOLFUROSEMIDE 40 MG/4 ML SYRINGEFUROSEMIDE 40 MG/4 ML VIALFUROSEMIDE 40 MG/5 ML SOLNFUROSEMIDE 80 MG TABLETGALANTAMINE 4 MG/ML ORAL SOLN GALANTAMINE 4 MG/ML ORAL SOLNGALANTAMINE ER 16 MG CAPSULE GALANTAMINE ER 16 MG CAPSULEGALANTAMINE ER 24 MG CAPSULE GALANTAMINE ER 24 MG CAPSULEGALANTAMINE ER 8 MG CAPSULE GALANTAMINE ER 8 MG CAPSULEGALANTAMINE HBR 12 MG TABLET GALANTAMINE HBR 12 MG TABLETGALANTAMINE HBR 4 MG TABLET GALANTAMINE HBR 4 MG TABLETGALANTAMINE HBR 8 MG TABLET GALANTAMINE HBR 8 MG TABLETGANCICLOVIR 500 MG VIALGANCICLOVIR 500 MG/10 ML VIALGATIFLOXACIN 0.5% EYE DROPS GATIFLOXACIN 0.5% EYE DROPSGATIFLOXACIN 0.5% EYE DROPSGAVILYTE-C SOLUTIONGAVILYTE-G SOLUTIONGAVILYTE-N SOLUTIONGEMFIBROZIL 600 MG TABLETGENERLAC 10 GM/15 ML SOLUTIONGENTAK 0.3 % EYE OINTMENTGENTAMICIN 0.1% CREAMGENTAMICIN 0.1% OINTMENT

F4 42

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

GENTAMICIN 0.3% EYE DROPGENTAMICIN 0.3% EYE OINTMENTGENTAMICIN 20 MG/2 ML VIALGENTAMICIN 3 MG/GM EYE OINTGENTAMICIN 3 MG/ML EYE DROPGENTAMICIN 40 MG/ML VIALGENTAMICIN 80 MG/2 ML VIALGENTAMICIN 800 MG/20 ML VIALGENTLE LAXATIVE 10 MG SUPPGENTLE LAXATIVE 10 MG SUPPOSITGENTLE LAXATIVE 5 MG TABLETGENTLE LAXATIVE EC 5 MG TABLETGENVOYA TABLETGILDAGIA 0.4 MG-0.035 MG TABGILDESS 1 MG-20 MCG TABLETGILDESS 1.5 MG-30 MCG TABLETGILDESS 24 FE 1-0.02 MG TABLETGILDESS FE 1.5-30 TABLETGILDESS FE 1-20 TABLETGILOTRIF 20 MG TABLETGILOTRIF 30 MG TABLETGILOTRIF 40 MG TABLETGLIMEPIRIDE 1 MG TABLETGLIMEPIRIDE 2 MG TABLETGLIMEPIRIDE 4 MG TABLETGLIPIZIDE 10 MG TABLETGLIPIZIDE 5 MG TABLETGLIPIZIDE ER 10 MG TABLETGLIPIZIDE ER 2.5 MG TABLET

F4 43

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

GLIPIZIDE ER 5 MG TABLETGLIPIZIDE XL 2.5 MG TABLETGLUCAGON 1 MG EMERGENCY KITGLUCAGON 1 MG VIALGLYBURIDE 1.25 MG TABLETGLYBURIDE 2.5 MG TABLETGLYBURIDE 5 MG TABLETGLYCERIN ADULT SUPPOSITORYGLYCERIN PEDIATRIC SUPPOSGLYCERIN PEDIATRIC SUPPOSITORYGLYCERIN SUPPOSITORYGLYXAMBI 10 MG-5 MG TABLET GLYXAMBI 10 MG-5 MG TABLETGLYXAMBI 25 MG-5 MG TABLET GLYXAMBI 25 MG-5 MG TABLETGOLYTELY PACKETGOLYTELY SOLUTIONGORDON'S UREA 40% OINTMENTGRISEOFULVIN 125 MG/5 ML SUSPGRISEOFULVIN MICRO 500 MG TABGRISEOFULVIN ULTRA 125 MG TABGRISEOFULVIN ULTRA 250 MG TABGUAIASORB DM LIQUIDGUAIATUSSIN AC LIQUIDGUAIFEN-CODEINE 100-10 MG/5 MLGUAIFEN-CODEINE 200-20 MG/10 MGUAIFENESIN 100 MG/5 ML LIQUIDGUAIFENESIN 100 MG/5 ML SOLNGUAIFENESIN 100 MG/5 ML SYRUPGUAIFENESIN 200 MG TABLETGUAIFENESIN 200 MG/10 ML SOLN

F4 44

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

GUAIFENESIN 300 MG/15 ML SOLNGUAIFENESIN 400 MG CAPLETGUAIFENESIN 400 MG TABLETGUAIFENESIN AC COUGH SYRUPGUAIFENESIN DM 400-20 MG TABGUAIFENESIN DM SYRUPGUAIFENESIN-CODEINE SYRUPGUAIFENESIN-DM 100-10 MG/5 MLGUAIFENESIN-DM 200-20 MG/10 MLGUAIFENESIN-DM 400-20 MG CPLTGUAIFENESIN-DM ER 1,200-60 MGGUANFACINE 1 MG TABLETGUANFACINE 2 MG TABLETGYNAZOLE 1 2% CREAMHAILEY 21 1.5 MG-30 MCG TABHAILEY 24 FE 1 MG-20 MCG TABHAIR, SKIN AND NAILS TABLETHARVONI 45-200 MG TABLET HARVONI 45-200 MG TABLETHEARTBURN & ACID REFLUX TABSHEARTBURN RELIEF 10 MG TABLETHEARTBURN RELIEF 150 MG TABHEARTBURN RELIEF 150 MG TABLETHEARTBURN RELIEF 20 MG TABLETHEARTBURN RELIEF 75 MG TABLETHEATHER 0.35 MG TABLETHEMOFIL M 1,000 UNIT NOMINAL HEMOFIL M 1,000 UNIT NOMINALHEMOFIL M 1,700 UNIT NOMINAL HEMOFIL M 1,700 UNIT NOMINALHEMOFIL M 1,701-2,000 UNITS VL HEMOFIL M 1,701-2,000 UNITS VLHEMOFIL M 250 UNIT NOMINAL HEMOFIL M 250 UNIT NOMINAL

F4 45

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

HEMOFIL M 500 UNIT NOMINAL HEMOFIL M 500 UNIT NOMINALHUMALOG 100 UNIT/ML VIALHUMALOG 100 UNITS/ML CARTRIDGEHUMALOG 100 UNITS/ML KWIKPENHUMALOG 100 UNITS/ML VIALHUMALOG 200 UNITS/ML KWIKPENHUMALOG MIX 50-50 KWIKPENHUMALOG MIX 50-50 VIALHUMALOG MIX 75-25 KWIKPENHUMALOG MIX 75-25 VIALHUMATE-P 1,200 UNIT VWF:RCO HUMATE-P 1,200 UNIT VWF:RCOHUMATE-P 2,400 UNIT VWF:RCO HUMATE-P 2,400 UNIT VWF:RCOHUMATE-P 600 UNIT VWF:RCO HUMATE-P 600 UNIT VWF:RCOHUMATROPE 12 MG CARTRIDGE HUMATROPE 12 MG CARTRIDGEHUMATROPE 24 MG CARTRIDGE HUMATROPE 24 MG CARTRIDGEHUMATROPE 5 MG VIAL HUMATROPE 5 MG VIALHUMATROPE 6 MG CARTRIDGE HUMATROPE 6 MG CARTRIDGEHUMIRA 10 MG/0.2 ML SYRINGE HUMIRA 10 MG/0.2 ML SYRINGEHUMIRA 10 MG/0.2 ML SYRINGEHUMIRA 20 MG/0.4 ML SYRINGE HUMIRA 20 MG/0.4 ML SYRINGEHUMIRA 20 MG/0.4 ML SYRINGEHUMIRA 40 MG/0.8 ML SYRINGE HUMIRA 40 MG/0.8 ML SYRINGEHUMIRA 40 MG/0.8 ML SYRINGEHUMIRA PEDIATRIC CROHN'S START HUMIRA PEDIATRIC CROHN'S STARTHUMIRA PEDIATRIC CROHN'S STARTHUMIRA PEN 40 MG/0.8 ML HUMIRA PEN 40 MG/0.8 ML HUMIRA PEN 40 MG/0.8 MLHUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN CROHN'S-UC-HS STARTHUMIRA PEN CROHN'S-UC-HS STARTHUMIRA PEN PSORIASIS-UVEITIS-A HUMIRA PEN PSORIASIS-UVEITIS-AHUMIRA PEN PSORIASIS-UVEITIS-AHUMIRA(CF) 10 MG/0.1 ML SYRING HUMIRA(CF) 10 MG/0.1 ML SYRINGHUMIRA(CF) 10 MG/0.1 ML SYRINGHUMIRA(CF) 20 MG/0.2 ML SYRING HUMIRA(CF) 20 MG/0.2 ML SYRINGHUMIRA(CF) 20 MG/0.2 ML SYRINGHUMIRA(CF) 40 MG/0.4 ML SYRING HUMIRA(CF) 40 MG/0.4 ML SYRINGHUMIRA(CF) 40 MG/0.4 ML SYRINGHUMIRA(CF) PEDIATRIC CROHN'S S HUMIRA(CF) PEDIATRIC CROHN'S SHUMIRA(CF) PEDIATRIC CROHN'S SHUMIRA(CF) PEN 40 MG/0.4 ML HUMIRA(CF) PEN 40 MG/0.4 MLHUMIRA(CF) PEN 40 MG/0.4 ML

F4 46

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

HUMIRA(CF) PEN CROHN'S-UC-HS S HUMIRA(CF) PEN CROHN'S-UC-HS SHUMIRA(CF) PEN CROHN'S-UC-HS SHUMIRA(CF) PEN PS-UV-ADOL HS S HUMIRA(CF) PEN PS-UV-ADOL HS SHUMIRA(CF) PEN PS-UV-ADOL HS SHUMULIN 70/30 KWIKPENHUMULIN 70-30 VIALHUMULIN N 100 UNIT/ML VIALHUMULIN N 100 UNITS/ML KWIKPENHUMULIN N 100 UNITS/ML VIALHUMULIN R 100 UNIT/ML VIALHUMULIN R 100 UNITS/ML VIALHUMULIN R 500 UNITS/ML VIALHV ALLERGY-CONGEST RLF ER TABHYDRALAZINE 10 MG TABLETHYDRALAZINE 100 MG TABLETHYDRALAZINE 20 MG/ML VIALHYDRALAZINE 25 MG TABLETHYDRALAZINE 50 MG TABLETHYDROCHLOROTHIAZIDE 12.5 MG TBHYDROCHLOROTHIAZIDE 25 MG TABHYDROCHLOROTHIAZIDE 50 MG TABHYDROCODONE-ACETAMINOPHEN 5-30HYDROCODONE-ACETAMINOPHEN 5-32HYDROCORTISON-ACETIC ACID SOLNHYDROCORTISONE 0.5% CREAMHYDROCORTISONE 0.5% OINTMENTHYDROCORTISONE 1% CREAMHYDROCORTISONE 1% OINTMENTHYDROCORTISONE 10 MG TABLETHYDROCORTISONE 2.5% CREAMHYDROCORTISONE 2.5% OINTMENT

F4 47

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

HYDROCORTISONE 20 MG TABLETHYDROCORTISONE 5 MG TABLETHYDROMORPHONE 2 MG TABLETHYDROMORPHONE 4 MG TABLETHYDROMORPHONE 8 MG TABLETHYDROXOCOBALAMIN 1,000 MCG/ML HYDROXOCOBALAMIN 1,000 MCG/MLHYDROXYCHLOROQUINE 200 MG TABHYDROXYPROGEST 1,250 MG/5 MLHYDROXYPROGEST 250 MG/ML VIALHYDROXYUREA 500 MG CAPSULEHYOSCYAMINE 0.125 MG TAB SLHYOSCYAMINE SULF 0.125 MG TABIBANDRONATE 3 MG/3 ML SYRINGEIBANDRONATE 3 MG/3 ML VIALIBANDRONATE SODIUM 150 MG TABIBU 400 MG TABLETIBU 600 MG TABLETIBU 800 MG TABLETIBU-200 200 MG TABLETIBUPROFEN 100 MG TABLETIBUPROFEN 100 MG/5 ML SUSPIBUPROFEN 200 MG CAPLETIBUPROFEN 200 MG CAPSULEIBUPROFEN 200 MG SOFTGELIBUPROFEN 200 MG TABLETIBUPROFEN 200 MG/10 ML SUSPIBUPROFEN 400 MG TABLETIBUPROFEN 50 MG/1.25 ML SUSPIBUPROFEN 600 MG TABLET

F4 48

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

IBUPROFEN 800 MG TABLETIBUPROFEN JR STR 100 MG TB CHWINCASSIA 0.35 MG TABLETINDAPAMIDE 1.25 MG TABLETINDAPAMIDE 2.5 MG TABLETINDOMETHACIN 25 MG CAPSULEINDOMETHACIN 50 MG CAPSULEINFUVITE ADULT VIALINFUVITE PEDIATRIC VIALINSULIN ASPART PROTAMINE-INSULINSULIN LISPROINTELENCE 100 MG TABLETINTELENCE 200 MG TABLETINTELENCE 25 MG TABLETINTRON A 10 MILLION UNITS VIAL INTRON A 10 MILLION UNITS VIALINTRON A 18 MILLION UNIT/3 ML INTRON A 18 MILLION UNIT/3 MLINTRON A 18 MILLION UNITS VIAL INTRON A 18 MILLION UNITS VIALINTRON A 25 MILLION UNIT/2.5 M INTRON A 25 MILLION UNIT/2.5 MINTRON A 50 MILLION UNITS VIAL INTRON A 50 MILLION UNITS VIALINTROVALE 0.15-0.03 MG TABLETIOPHEN DM-NR LIQUIDIOPHEN-C NR LIQUIDIPECAC SYRUPIPRATROPIUM 0.03% SPRAYIPRATROPIUM 0.06% SPRAYIPRATROPIUM BR 0.02% SOLNIPRATROPIUM-ALBUTEROL 0.5-3(2.IRBESARTAN 150 MG TABLETIRBESARTAN 300 MG TABLET

F4 49

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

IRBESARTAN 75 MG TABLETIRBESARTAN-HYDROCHLOROTHIAZIDEIRON 27 MG TABLETIRON 28 MG TABLETIRON 65 MG TABLETISENTRESS 100 MG POWDER PACKETISENTRESS 100 MG TABLET CHEWISENTRESS 25 MG TABLET CHEWISENTRESS 400 MG TABLETISENTRESS HD 600 MG TABLETISIBLOOM 28 DAY TABLETISONIAZID 100 MG TABLETISONIAZID 100 MG/ML VIALISONIAZID 300 MG TABLETISONIAZID 50 MG/5 ML SOLUTIONISOPROPYL ALCOHOL 70% WIPESISORDIL 40 MG TABLETISOSORBIDE DINITR ER 40 MG TABISOSORBIDE DINITRATE 10 MG TABISOSORBIDE DINITRATE 20 MG TABISOSORBIDE DINITRATE 30 MG TABISOSORBIDE DINITRATE 40 MG TABISOSORBIDE DINITRATE 5 MG TABISOSORBIDE MONONIT 10 MG TAB ISOSORBIDE MONONIT 10 MG TABISOSORBIDE MONONIT 10 MG TABISOSORBIDE MONONIT 20 MG TAB ISOSORBIDE MONONIT 20 MG TABISOSORBIDE MONONIT 20 MG TABISOSORBIDE MONONIT ER 120 MG ISOSORBIDE MONONIT ER 120 MGISOSORBIDE MONONIT ER 120 MGISOSORBIDE MONONIT ER 30 MG TB ISOSORBIDE MONONIT ER 30 MG TBISOSORBIDE MONONIT ER 30 MG TBISOSORBIDE MONONIT ER 60 MG TB ISOSORBIDE MONONIT ER 60 MG TBISOSORBIDE MONONIT ER 60 MG TBITRACONAZOLE 10 MG/ML SOLUTION ITRACONAZOLE 10 MG/ML SOLUTION

F4 50

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ITRACONAZOLE 100 MG CAPSULE ITRACONAZOLE 100 MG CAPSULEIVERMECTIN 1% CREAMIVERMECTIN 3 MG TABLETJANTOVEN 1 MG TABLETJANTOVEN 10 MG TABLETJANTOVEN 2 MG TABLETJANTOVEN 2.5 MG TABLETJANTOVEN 3 MG TABLETJANTOVEN 4 MG TABLETJANTOVEN 5 MG TABLETJANTOVEN 6 MG TABLETJANTOVEN 7.5 MG TABLETJANUVIA 100 MG TABLET JANUVIA 100 MG TABLET JANUVIA 100 MG TABLETJANUVIA 25 MG TABLET JANUVIA 25 MG TABLET JANUVIA 25 MG TABLETJANUVIA 50 MG TABLET JANUVIA 50 MG TABLET JANUVIA 50 MG TABLETJASMIEL 3 MG-0.02 MG TABLETJENCYCLA 0.35 MG TABLETJOCK ITCH 1% CREAMJOCK ITCH RELIEF 1% CREAMJOLESSA 0.15 MG-0.03 MG TABLETJR ACETAMINOPHEN 160 MG TABLETJR PAIN-FEVER 160 MG RAPID TABJULEBER 28 DAY TABLETJULUCA 50-25 MG TABLETJUNEL 1 MG-20 MCG TABLETJUNEL 1.5 MG-30 MCG TABLETJUNEL FE 1 MG-20 MCG TABLETJUNEL FE 1.5 MG-30 MCG TABLETJUNEL FE 24 TABLET

F4 51

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

KAITLIB FE CHEWABLE TABLETKALETRA 80 MG-20 MG/ML SOLNKALLIGA 28 DAY TABLETKARIVA 28 DAY TABLETKELNOR 1-35 28 TABLETKELNOR 1-50 TABLETKENDALL ALCOHOL 70% PREP PADKETOCONAZOLE 2% CREAMKETOCONAZOLE 2% FOAMKETOCONAZOLE 2% SHAMPOOKETOCONAZOLE 200 MG TABLETKETONE TEST STRIPKETOSTIX REAGENT STRIPKETOTIFEN FUM 0.025% EYE DROPSKIMIDESS 28 DAY TABLETKIMONO CONDOMSKIMONO MAXX CONDOMKIMONO MICROTHIN AQUA LUBEKIMONO MICROTHIN CONDOMKIMONO MICROTHIN LARGE CONDOMKIMONO TEXTURED CONDOMKIONEX 15 GM/60 ML SUSPENSIONKIONEX POWDERKOATE 1,000 UNIT VIAL KOATE 1,000 UNIT VIALKOATE 250 UNIT VIAL KOATE 250 UNIT VIALKOATE 500 UNIT VIAL KOATE 500 UNIT VIALKOATE-DVI 1,000 UNIT VIAL KOATE-DVI 1,000 UNIT VIALKOATE-DVI 250 UNIT VIAL KOATE-DVI 250 UNIT VIALKOATE-DVI 500 UNIT VIAL KOATE-DVI 500 UNIT VIAL

F4 52

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

K-TAB ER 10 MEQ TABLETK-TAB ER 20 MEQ TABLETK-TAB ER 8 MEQ TABLETKURVELO TABLETLABETALOL HCL 100 MG TABLETLABETALOL HCL 100 MG/20 ML VLLABETALOL HCL 20 MG/4 ML CRPJTLABETALOL HCL 20 MG/4 ML SYRLABETALOL HCL 20 MG/4 ML SYRINLABETALOL HCL 200 MG TABLETLABETALOL HCL 200 MG/40 ML VLLABETALOL HCL 25 MG/5 ML SYRLABETALOL HCL 25 MG/5 ML SYRINLABETALOL HCL 300 MG TABLETLABETALOL HCL 50 MG/10 ML SYRILABETALOL HCL 50 MG/10 ML SYRNLAC-HYDRIN FIVE 5% LOTIONLACTIC ACID 10% LOTIONLACTULOSE 10 GM PACKETLACTULOSE 10 GM/15 ML SOLUTIONLACTULOSE 20 GM/30 ML SOLUTIONLAMIVUDINE 10 MG/ML ORAL SOLNLAMIVUDINE 100 MG TABLETLAMIVUDINE 150 MG TABLETLAMIVUDINE 300 MG TABLETLAMIVUDINE HBV 100 MG TABLETLAMIVUDINE-ZIDOVUDINE TABLETLANOXIN 0.25 MG TABLETLANOXIN 125 MCG TABLET

F4 53

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

LANOXIN 187.5 MCG TABLETLANOXIN 250 MCG TABLETLANOXIN 500 MCG/2 ML VIALLANOXIN 62.5 MCG TABLETLANSOPRAZOLE DR 15 MG CAPSULELANSOPRAZOLE DR 30 MG CAPSULELANSOPRAZOLE ODT 15 MG TABLET LANSOPRAZOLE ODT 15 MG TABLETLANSOPRAZOLE ODT 30 MG TABLET LANSOPRAZOLE ODT 30 MG TABLETLANTUS 100 UNIT/ML VIALLANTUS SOLOSTAR 100 UNIT/MLLARIN 1.5 MG-30 MCG TABLETLARIN 21 1-20 TABLETLARIN 24 FE 1 MG-20 MCG TABLETLARIN FE 1.5-30 TABLETLARIN FE 1-20 TABLETLARISSIA-28 TABLETLATANOPROST 0.005% EYE DROPSLAXATIVE 10 MG SUPPOSITORYLAXATIVE 5 MG TABLETLAXATIVE EC 5 MG TABLETLEDIPASVIR-SOFOSBUVIR 90-400 M LEDIPASVIR-SOFOSBUVIR 90-400 MLESSINA-28 TABLETLETROZOLE 2.5 MG TABLETLEUCOVORIN CALCIUM 10 MG TABLEUCOVORIN CALCIUM 15 MG TABLEUCOVORIN CALCIUM 25 MG TABLEUCOVORIN CALCIUM 5 MG TABLEVOFLOXACIN 0.5% EYE DROPSLEVOFLOXACIN 25 MG/ML SOLUTION

F4 54

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

LEVOFLOXACIN 250 MG TABLETLEVOFLOXACIN 250 MG/10 ML SOLNLEVOFLOXACIN 500 MG TABLETLEVOFLOXACIN 500 MG/20 ML SOLNLEVOFLOXACIN 500 MG/20 ML VIALLEVOFLOXACIN 750 MG TABLETLEVOFLOXACIN 750 MG/30 ML VIALLEVOMEFOLATE DHA CAPSULELEVONEST-28 TABLETLEVONO-E ESTRAD 0.10-0.02-0.01LEVONO-E ESTRAD 0.15-0.03-0.01LEVONOR-ETH ESTRA 0.09-0.02 MGLEVONOR-ETH ESTRAD 0.1-0.02 MGLEVONOR-ETH ESTRAD 0.15-0.03LEVONOR-ETH ESTRAD TRIPHASICLEVONORG 0.15 MG-EE 20-25-30 MLEVONORGESTREL 0.75 MG TABLETLEVONORGESTREL 1.5 MG TABLETLEVONORGESTREL-ETH ESTRAD 0.15LEVORA-28 TABLETLEVOTHYROXINE 0.025 MG TABLETLEVOTHYROXINE 0.05 MG TABLETLEVOTHYROXINE 0.075 MG TABLETLEVOTHYROXINE 0.088 MG TABLETLEVOTHYROXINE 0.1 MG TABLETLEVOTHYROXINE 0.112 MG TABLETLEVOTHYROXINE 0.125 MG TABLETLEVOTHYROXINE 0.137 MG TABLETLEVOTHYROXINE 0.15 MG TABLET

F4 55

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

LEVOTHYROXINE 0.175 MG TABLETLEVOTHYROXINE 100 MCG TABLETLEVOTHYROXINE 100 MCG VIALLEVOTHYROXINE 100 MCG/5 ML VLLEVOTHYROXINE 112 MCG TABLETLEVOTHYROXINE 125 MCG TABLETLEVOTHYROXINE 137 MCG TABLETLEVOTHYROXINE 150 MCG TABLETLEVOTHYROXINE 175 MCG TABLETLEVOTHYROXINE 200 MCG TABLETLEVOTHYROXINE 200 MCG VIALLEVOTHYROXINE 200 MCG/5 ML VLLEVOTHYROXINE 25 MCG TABLETLEVOTHYROXINE 300 MCG TABLETLEVOTHYROXINE 50 MCG TABLETLEVOTHYROXINE 500 MCG VIALLEVOTHYROXINE 500 MCG/5 ML VLLEVOTHYROXINE 75 MCG TABLETLEVOTHYROXINE 88 MCG TABLETLICE TREATMENT 1% CREME RINSELIDOCAINE 2% VISCOUS SOLNLIDOCAINE 3% CREAMLIDOCAINE 5% OINTMENTLIDOCAINE 5% PATCH LIDOCAINE 5% PATCH LIDOCAINE 5% PATCHLIDOCAINE HCL 2% JELLYLIDOCAINE-PRILOCAINE CREAMLIFE-PACK MEN'SLIFE-PACK WOMEN'SLILLOW-28 TABLET

F4 56

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

LINDANE 1% LOTIONLINDANE 1% SHAMPOOLIOTHYRONINE SOD 10 MCG/ML VLLIOTHYRONINE SOD 25 MCG TABLIOTHYRONINE SOD 5 MCG TABLIOTHYRONINE SOD 50 MCG TABLIQUID ANTACID SUSPENSIONLISINOPRIL 10 MG TABLETLISINOPRIL 2.5 MG TABLETLISINOPRIL 20 MG TABLETLISINOPRIL 30 MG TABLETLISINOPRIL 40 MG TABLETLISINOPRIL 5 MG TABLETLISINOPRIL-HYDROCHLOROTHIAZIDELO LOESTRIN FE 1-10 TABLETLOESTRIN 21 1.5-30 TABLETLOESTRIN 21 1-20 TABLETLOESTRIN FE 1.5-30 TABLETLOESTRIN FE 1-20 TABLETLOMEDIA 24 FE 1 MG-20 MCG TABLOMOTIL 2.5-0.025 MG TABLETLOMUSTINE 10 MG CAPSULELOMUSTINE 100 MG CAPSULELOMUSTINE 40 MG CAPSULELOPERAMIDE 1 MG/5 ML LIQUIDLOPERAMIDE 1 MG/5 ML SOLUTIONLOPERAMIDE 1 MG/7.5 ML LIQUIDLOPERAMIDE 1 MG/7.5 ML SOLNLOPERAMIDE 1 MG/7.5 ML SUSP

F4 57

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

LOPERAMIDE 2 MG CAPLETLOPERAMIDE 2 MG CAPSULELOPERAMIDE 2 MG TABLETLOPERAMIDE 2 MG/15 ML SUSPLOPINAVIR-RITONAVIR 80-20 MG/MLORATADINE 10 MG ODTLORATADINE 10 MG SOFTGELLORATADINE 10 MG TABLETLORATADINE 5 MG/5 ML SOLNLORATADINE 5 MG/5 ML SOLUTIONLORATADINE 5 MG/5 ML SYRUPLORATADINE ALLERGY 5 MG/5 MLLORATADINE HIVES 5 MG/5 MLLORATADINE-D 12 HOUR TABLETLORATADINE-D 24HR TABLETLORYNA 3 MG-0.02 MG TABLETLOSARTAN POTASSIUM 100 MG TABLOSARTAN POTASSIUM 25 MG TABLOSARTAN POTASSIUM 50 MG TABLOSARTAN-HYDROCHLOROTHIAZIDE 1LOSARTAN-HYDROCHLOROTHIAZIDE 5LOSEASONIQUE TABLETLOVASTATIN 10 MG TABLETLOVASTATIN 20 MG TABLETLOVASTATIN 40 MG TABLETLOW DOSE ASPIRIN EC 81 MG TABLOW-OGESTREL-28 TABLETLO-ZUMANDIMINE 3 MG-0.02 MG TBLUPRON DEPOT 11.25 MG 3MO KIT LUPRON DEPOT 11.25 MG 3MO KITLUPRON DEPOT 11.25 MG 3MO KIT

F4 58

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT 22.5 MG 3MO KITLUPRON DEPOT 22.5 MG 3MO KITLUPRON DEPOT 3.75 MG KIT LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT 3.75 MG KITLUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT 45 MG 6MO KITLUPRON DEPOT 45 MG 6MO KITLUPRON DEPOT 7.5 MG KIT LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT 7.5 MG KITLUPRON DEPOT-4 MONTH KIT LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT-4 MONTH KITLUTERA-28 TABLETMAGLOX LIQUIDMAGNESIUM CITRATE 100 MG TABMAGNESIUM CITRATE 125 MG SFTGLMAGNESIUM CITRATE SOLUTIONMAKENA 1,250 MG/5 ML VIALMAKENA 250 MG/ML VIALMAKENA 275 MG/1.1 ML AUTOINJCTMAPAP 120 MG/3.75 ML ORAL SYRNMAPAP 16 MG/0.5 ML ORAL SYRNGEMAPAP 160 MG/5 ML LIQUIDMAPAP 160 MG/5 ML ORAL SYRINGEMAPAP 160 MG/5 ML SUSPENSIONMAPAP 200 MG/6.25 ML ORAL SYRNMAPAP 22.4 MG/0.7 ML ORAL SYRNMAPAP 240 MG/7.5 ML LIQUIDMAPAP 240 MG/7.5 ML ORAL SYRNGMAPAP 32 MG/ML ORAL SYRINGEMAPAP 325 MG TABLETMAPAP 325 MG/10.15 ML LIQUIDMAPAP 40 MG/1.25 ML ORAL SYRNGMAPAP 48 MG/1.5 ML ORAL SYRNGEMAPAP 480 MG/15 ML LIQUIDMAPAP 500 MG CAPLET

F4 59

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

MAPAP 500 MG CAPSULEMAPAP 500 MG GELCAPMAPAP 500 MG TABLETMAPAP 500 MG/15 ML LIQUIDMAPAP 64 MG/2 ML ORAL SYRINGEMAPAP 650 MG/20.3 ML LIQUIDMAPAP 80 MG/2.5 ML ORAL SYRNGEMAPAP 9.6 MG/0.3 ML ORAL SYRNGMAPAP ARTHRITIS ER 650 MG CPLTMAPAP INFANT 80 MG/0.8 ML DROPMARLISSA-28 TABLETMATULANE 50 MG CAPSULEMAVYRET 100-40 MG TABLET MAVYRET 100-40 MG TABLETMECLIZINE 12.5 MG CAPLETMECLIZINE 12.5 MG TABLETMECLIZINE 25 MG TABLETMECLIZINE 25 MG TABLET CHEWMEDROXYPROGESTERONE 10 MG TABMEDROXYPROGESTERONE 150 MG/MLMEDROXYPROGESTERONE 2.5 MG TABMEDROXYPROGESTERONE 5 MG TABMEGESTROL 20 MG TABLETMEGESTROL 40 MG TABLETMEGESTROL 625 MG/5 ML SUSPMEGESTROL 800 MG/20 ML SUSPMEGESTROL ACET 40 MG/ML SUSPMEGESTROL ACET 400 MG/10 MLMEGESTROL ACET 800 MG/20 MLMELODETTA 24 FE CHEWABLE TAB

F4 60

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

MELOXICAM 15 MG TABLETMELOXICAM 7.5 MG TABLETMELOXICAM 7.5 MG/5 ML SUSPMELPHALAN 50 MG VIAL W-DILUENTMELPHALAN HCL 50 MG VIALMEMANTINE 5-10 MG TITRATION PK MEMANTINE 5-10 MG TITRATION PKMEMANTINE HCL 10 MG TABLET MEMANTINE HCL 10 MG TABLETMEMANTINE HCL 10 MG/5 ML SOLN MEMANTINE HCL 10 MG/5 ML SOLNMEMANTINE HCL 2 MG/ML SOLUTION MEMANTINE HCL 2 MG/ML SOLUTIONMEMANTINE HCL 5 MG TABLET MEMANTINE HCL 5 MG TABLETMEMANTINE HCL ER 14 MG CAPSULE MEMANTINE HCL ER 14 MG CAPSULEMEMANTINE HCL ER 21 MG CAPSULE MEMANTINE HCL ER 21 MG CAPSULEMEMANTINE HCL ER 28 MG CAPSULE MEMANTINE HCL ER 28 MG CAPSULEMEMANTINE HCL ER 7 MG CAPSULE MEMANTINE HCL ER 7 MG CAPSULEMEN 50 PLUS MULTIVITAMIN TABMENEST 0.3 MG TABLETMENEST 0.625 MG TABLETMENEST 1.25 MG TABLETMENEST 2.5 MG TABLETMEPERIDINE 100 MG TABLETMEPERIDINE 50 MG TABLETMEPERIDINE 50 MG/5 ML SOLUTIONMEPHYTON 5 MG TABLET MEPHYTON 5 MG TABLETMERCAPTOPURINE 50 MG TABLETMESALAMINE 1,000 MG SUPPMESALAMINE 4 GM/60 ML ENEMAMESALAMINE 800 MG DR TABLETMESALAMINE DR 1.2 GM TABLETMETAXALONE 400 MG TABLET

F4 61

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

METAXALONE 800 MG TABLETMETFORMIN HCL 1,000 MG TABLETMETFORMIN HCL 500 MG TABLETMETFORMIN HCL 850 MG TABLETMETHADONE 10 MG/5 ML SOLUTION METHADONE 10 MG/5 ML SOLUTIONMETHADONE 10 MG/ML ORAL CONC METHADONE 10 MG/ML ORAL CONCMETHADONE 40 MG TABLET DISPR METHADONE 40 MG TABLET DISPRMETHADONE 5 MG/5 ML SOLUTION METHADONE 5 MG/5 ML SOLUTIONMETHADONE HCL 10 MG TABLET METHADONE HCL 10 MG TABLETMETHADONE HCL 10 MG/ML SYRINGE METHADONE HCL 10 MG/ML SYRINGEMETHADONE HCL 10 MG/ML VIAL METHADONE HCL 10 MG/ML VIALMETHADONE HCL 200 MG/20 ML VL METHADONE HCL 200 MG/20 ML VLMETHADONE HCL 5 MG TABLET METHADONE HCL 5 MG TABLETMETHAZOLAMIDE 25 MG TABLETMETHAZOLAMIDE 50 MG TABLETMETHENAMINE MD 1 GM TABLETMETHENAMINE MD 500 MG TABLETMETHIMAZOLE 10 MG TABLETMETHIMAZOLE 5 MG TABLETMETHOCARBAMOL 1,000 MG/10 MLMETHOCARBAMOL 500 MG TABLETMETHOCARBAMOL 750 MG TABLETMETHOTREXATE 1 GM VIALMETHOTREXATE 1 GRAM/40 ML VIALMETHOTREXATE 100 MG/4 ML VIALMETHOTREXATE 2.5 MG TABLETMETHOTREXATE 200 MG/8 ML VIALMETHOTREXATE 25 MG/ML VIALMETHOTREXATE 250 MG/10 ML VIAL

F4 62

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

METHOTREXATE 50 MG/2 ML VIALMETHYCLOTHIAZIDE 5 MG TABLETMETHYLDOPA 250 MG TABLETMETHYLDOPA 500 MG TABLETMETHYLDOPA-HYDROCHLOROTHIAZIDEMETHYLERGONOVINE 0.2 MG TABLETMETHYLERGONOVINE 0.2 MG/ML AMPMETHYLERGONOVINE 0.2 MG/ML VLMETHYLPREDNISOLONE 16 MG TABMETHYLPREDNISOLONE 32 MG TABMETHYLPREDNISOLONE 4 MG DOSEPKMETHYLPREDNISOLONE 4 MG TABLETMETHYLPREDNISOLONE 8 MG TABMETOCLOPRAMIDE 10 MG TABLETMETOCLOPRAMIDE 5 MG/5 ML SOLNMETOCLOPRAMIDE HCL 10 MG ODTMETOCLOPRAMIDE HCL 5 MG ODTMETOLAZONE 10 MG TABLETMETOLAZONE 2.5 MG TABLETMETOLAZONE 5 MG TABLETMETOPROLOL 5 MG/5 ML CARPUJECTMETOPROLOL SUCC ER 100 MG TABMETOPROLOL SUCC ER 200 MG TABMETOPROLOL SUCC ER 25 MG TABMETOPROLOL SUCC ER 50 MG TABMETOPROLOL TART 5 MG/5 ML AMPMETOPROLOL TART 5 MG/5 ML VIALMETOPROLOL TARTRATE 100 MG TABMETOPROLOL TARTRATE 25 MG TAB

F4 63

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

METOPROLOL TARTRATE 37.5 MG TBMETOPROLOL TARTRATE 50 MG TABMETOPROLOL TARTRATE 75 MG TABMETRONIDAZOLE 0.75% CREAMMETRONIDAZOLE 0.75% LOTIONMETRONIDAZOLE 250 MG TABLETMETRONIDAZOLE 375 MG CAPSULEMETRONIDAZOLE 500 MG TABLETMETRONIDAZOLE TOPICAL 0.75% GLMETRONIDAZOLE TOPICAL 1% GELMETRONIDAZOLE VAGINAL 0.75% GL METRONIDAZOLE VAGINAL 0.75% GLMEXILETINE 150 MG CAPSULEMEXILETINE 200 MG CAPSULEMEXILETINE 250 MG CAPSULEMIACALCIN 200 UNIT/ML VIAL MIACALCIN 200 UNIT/ML VIAL MIACALCIN 200 UNIT/ML VIALMIACALCIN 400 UNIT/2 ML VIAL MIACALCIN 400 UNIT/2 ML VIALMIACALCIN 400 UNIT/2 ML VIALMIBELAS 24 FE CHEWABLE TABLETMICONAZOLE 100 MG VAG SUPPMICONAZOLE 2% SPRAY POWDERMICONAZOLE 2% TOPICAL CREAMMICONAZOLE 2% VAGINAL CREAMMICONAZOLE 3 200 MG VAG SUPPMICONAZOLE 3 4% CREAMMICONAZOLE NITRATE 2% CREAMMICONAZOLE-7 CREAMMICROGESTIN 21 1-20 TABLETMICROGESTIN FE 1-20 TABLETMIDODRINE HCL 10 MG TABLETMIDODRINE HCL 2.5 MG TABLET

F4 64

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

MIDODRINE HCL 5 MG TABLETMILI 0.25-0.035 MG TABLETMILLIPRED 10 MG/5 ML SOLUTIONMINOXIDIL 10 MG TABLETMINOXIDIL 2.5 MG TABLETMIRCETTE 28 DAY TABLETMOMETASONE FUROATE 50 MCG SPRYMONO-LINYAH 28 TABLETMONONESSA 28 TABLETMONTELUKAST SOD 10 MG TABLETMONTELUKAST SOD 4 MG GRANULESMONTELUKAST SOD 4 MG TAB CHEWMONTELUKAST SOD 5 MG TAB CHEWMORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 100 MG TABLETMORPHINE SULF ER 15 MG TABLET MORPHINE SULF ER 15 MG TABLETMORPHINE SULF ER 200 MG TABLET MORPHINE SULF ER 200 MG TABLETMORPHINE SULF ER 30 MG TABLET MORPHINE SULF ER 30 MG TABLETMORPHINE SULF ER 60 MG TABLET MORPHINE SULF ER 60 MG TABLETMORPHINE SULFATE IR 15 MG TABMORPHINE SULFATE IR 30 MG TABMOVIPREP POWDER PACKETMOXIFLOXACIN 0.5% EYE DROPMOXIFLOXACIN 0.5% EYE DROPSMOXIFLOXACIN HCL 400 MG TABLET MOXIFLOXACIN HCL 400 MG TABLETMUCUS RELIEF CONGEST-COUGH LIQMUCUS RELIEF COUGH LIQUIDMUCUS RELIEF DM MAX LIQUIDMUCUS RELIEF DM TABLETMULTIVIT-FLUORIDE 1 MG TAB CHW

F4 65

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

MUPIROCIN 2% CREAMMUPIROCIN 2% OINT TOPICAL SYRGMUPIROCIN 2% OINTMENTMVC-FLUORIDE 1 MG TAB CHEWMYCOPHENOLATE 200 MG/ML SUSPMYCOPHENOLATE 250 MG CAPSULEMYCOPHENOLATE 500 MG TABLETMYCOPHENOLIC ACID DR 180 MG TBMYCOPHENOLIC ACID DR 360 MG TBMYRBETRIQ ER 25 MG TABLET MYRBETRIQ ER 25 MG TABLETMYRBETRIQ ER 50 MG TABLET MYRBETRIQ ER 50 MG TABLETMYZILRA-28 TABLETNAC 500 MG CAPSULENAC 600 MG CAPSULEN-ACETYL-L-CYSTEINE 600 MG CAPNAMENDA 2 MG/ML SOLUTION NAMENDA 2 MG/ML SOLUTIONNAMENDA XR 14 MG CAPSULE NAMENDA XR 14 MG CAPSULENAMENDA XR 21 MG CAPSULE NAMENDA XR 21 MG CAPSULENAMENDA XR 28 MG CAPSULE NAMENDA XR 28 MG CAPSULENAMENDA XR 7 MG CAPSULE NAMENDA XR 7 MG CAPSULENAMENDA XR TITRATION PACK NAMENDA XR TITRATION PACKNAPHAZOLINE 0.1% EYE DROPSNAPROXEN 250 MG TABLETNAPROXEN 375 MG TABLETNAPROXEN 500 MG TABLETNAPROXEN SODIUM 275 MG TABNAPROXEN SODIUM 550 MG TABNASACORT ALLERGY 24HR SPRAYNASONEX 50 MCG NASAL SPRAY

F4 66

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

NATAZIA 28 TABLETNATELLE ONE CAPSULENECON 0.5-35-28 TABLETNECON 1-35-28 TABLETNEO-BACIT-POLY-HC EYE OINTMENTNEOMYC-BACIT-POLYMIX EYE OINTNEOMYCIN 500 MG TABLETNEOMYCIN-POLY-HC EYE DROPSNEOMYCIN-POLYMYXIN-HC EAR SOLNNEOMYCIN-POLYMYXIN-HC EAR SUSPNEOMYC-POLYM-DEXAMET EYE OINTMNEOMYC-POLYM-DEXAMETH EYE DROPNEOMYC-POLYM-GRAMICID EYE DROPNEO-POLYCIN EYE OINTMENTNESTABS ABC PRENATAL COMBO PKNESTABS DHA COMBO PACKNESTABS ONE SOFTGELNEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN 300 MCG/0.5 ML SYRNEUPOGEN 300 MCG/ML VIAL NEUPOGEN 300 MCG/ML VIALNEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN 480 MCG/0.8 ML SYRNEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN 480 MCG/1.6 ML VIALNEUTRAL SODIUM FLUORIDENEVIRAPINE 200 MG TABLETNEVIRAPINE 50 MG/5 ML SUSPNEVIRAPINE ER 100 MG TABLETNEVIRAPINE ER 400 MG TABLETNEXA PLUS SOFTGELNEXAVAR 200 MG TABLETNEXIUM 24HR 20 MG CAPSULE

F4 67

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

NEXIUM 24HR 20 MG TABLETNIACIN 100 MG TABLETNIACIN 250 MG TABLETNIACIN 50 MG TABLETNIACIN 500 MG TABLETNIACIN ER 1,000 MG TABLETNIACIN ER 250 MG TABLETNIACIN ER 500 MG TABLETNIACIN ER 750 MG TABLETNIFEDIPINE 10 MG CAPSULENIFEDIPINE 20 MG CAPSULENIFEDIPINE ER 30 MG TABLETNIFEDIPINE ER 60 MG TABLETNIFEDIPINE ER 90 MG TABLETNIKKI 3 MG-0.02 MG TABLETNITROFURANTOIN 25 MG/5 ML SUSPNITROFURANTOIN MCR 100 MG CAPNITROFURANTOIN MCR 25 MG CAPNITROFURANTOIN MCR 50 MG CAPNITROFURANTOIN MONO-MCR 100 MGNITROGLYCERIN 0.1 MG/HR PATCHNITROGLYCERIN 0.2 MG/HR PATCHNITROGLYCERIN 0.3 MG TABLET SLNITROGLYCERIN 0.4 MG TABLET SLNITROGLYCERIN 0.4 MG/HR PATCHNITROGLYCERIN 0.6 MG TABLET SLNITROGLYCERIN 0.6 MG/HR PATCHNITROSTAT 0.3 MG TABLET SLNITROSTAT 0.4 MG TABLET SL

F4 68

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

NITROSTAT 0.6 MG TABLET SLNON ASPIRIN 500 MG CAPLETNON-ASPIRIN 160 MG/5 ML SUSPNON-ASPIRIN 500 MG CAPLETNON-ASPIRIN 500 MG GELCAPNON-ASPIRIN 500 MG GELTABNON-ASPIRIN 500 MG SOFTGELNON-ASPIRIN 500 MG TABLETNON-ASPIRIN CHILD 120 MG SUPNON-ASPIRIN X-STR 167 MG/5 MLNON-DROWSY ALLERGY 10 MG TABNORET-ESTR-FE 0.4-0.035(21)-75NORETH-EE-FE 1.5-0.03 MG(21)-7NORETH-ESTRAD-FE 1-0.02(21)-75NORETH-ESTRAD-FE 1-0.02(24)-75NORETHIND-ETH ESTRAD 1-0.02 MGNORETHINDRONE 0.35 MG TABLETNORETHINDRONE 5 MG TABLETNORETHIN-EE 1.5-0.03 MG(21) TBNORETHIN-ESTRA-FE 0.8-0.025 MGNORG-EE 0.18-0.215-0.25/0.025NORG-EE 0.18-0.215-0.25/0.035NORG-ETHIN ESTR 0.5-0.05 MG TANORG-ETHIN ESTR 0.5-0.05 MG TBNORG-ETHIN ESTRA 0.25-0.035 MGNORINYL 1+50-28 TABLETNORLYDA 0.35 MG TABLETNORLYROC 0.35 MG TABLETNORTREL 0.5-35-28 TABLET

F4 69

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

NORTREL 1-35 28 TABLETNORTREL 7-7-7-28 TABLETNORVIR 100 MG TABLETNOVAFERRUM PED MULTIVIT-IRONNOVAMV MULTIVITAMIN DROPNOVOLIN 70-30 100 UNIT/ML VIALNOVOLIN 70-30 FLEXPENNOVOLIN N 100 UNIT/ML VIALNOVOLIN R 100 UNIT/ML VIALNOVOLOG 100 UNIT/ML CARTRIDGENOVOLOG 100 UNIT/ML FLEXPENNOVOLOG 100 UNIT/ML VIALNOVOLOG 100 UNITS/ML FLEXPENNOVOLOG MIX 70-30 FLEXPENNOVOLOG MIX 70-30 FLEXPEN SYRNNOVOLOG MIX 70-30 VIALNP THYROID 120 MG TABLETNP THYROID 15 MG TABLETNP THYROID 30 MG TABLETNP THYROID 60 MG TABLETNP THYROID 90 MG TABLETNUVARING VAGINAL RINGNYSTATIN 100,000 UNIT/GM CREAMNYSTATIN 100,000 UNIT/GM OINTNYSTATIN 100,000 UNIT/ML SUSPNYSTATIN 150,000,000 UNITS PWDNYSTATIN 50,000,000 UNITS PWDNYSTATIN 500,000 UNIT ORAL TABNYSTATIN 500,000 UNIT/5 ML SUS

F4 70

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

NYSTATIN-TRIAMCINOLONE CREAMNYSTATIN-TRIAMCINOLONE OINTMOB COMPLETE ONE SOFTGELOB COMPLETE PETITE SOFTGELOB COMPLETE PREMIER TABLETOB COMPLETE WITH DHA SOFTGELOBTREX DHA COMBO PACKO-CAL FA TABLETOCELLA 3 MG-0.03 MG TABLETOCTREOTIDE 1,000 MCG/5 ML VIAL OCTREOTIDE 1,000 MCG/5 ML VIALOCTREOTIDE 1,000 MCG/5 ML VIALOCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE 1,000 MCG/ML VIALOCTREOTIDE 1,000 MCG/ML VIALOCTREOTIDE 5,000 MCG/5 ML VIAL OCTREOTIDE 5,000 MCG/5 ML VIALOCTREOTIDE 5,000 MCG/5 ML VIALOCTREOTIDE ACET 0.05 MG/ML VL OCTREOTIDE ACET 0.05 MG/ML VLOCTREOTIDE ACET 0.05 MG/ML VLOCTREOTIDE ACET 100 MCG/ML AMP OCTREOTIDE ACET 100 MCG/ML AMPOCTREOTIDE ACET 100 MCG/ML AMPOCTREOTIDE ACET 100 MCG/ML SYR OCTREOTIDE ACET 100 MCG/ML SYROCTREOTIDE ACET 100 MCG/ML SYROCTREOTIDE ACET 100 MCG/ML VL OCTREOTIDE ACET 100 MCG/ML VLOCTREOTIDE ACET 100 MCG/ML VLOCTREOTIDE ACET 200 MCG/ML VL OCTREOTIDE ACET 200 MCG/ML VLOCTREOTIDE ACET 200 MCG/ML VLOCTREOTIDE ACET 50 MCG/ML AMP OCTREOTIDE ACET 50 MCG/ML AMPOCTREOTIDE ACET 50 MCG/ML AMPOCTREOTIDE ACET 50 MCG/ML SYR OCTREOTIDE ACET 50 MCG/ML SYROCTREOTIDE ACET 50 MCG/ML SYROCTREOTIDE ACET 50 MCG/ML VIAL OCTREOTIDE ACET 50 MCG/ML VIALOCTREOTIDE ACET 50 MCG/ML VIALOCTREOTIDE ACET 500 MCG/ML AMP OCTREOTIDE ACET 500 MCG/ML AMPOCTREOTIDE ACET 500 MCG/ML AMPOCTREOTIDE ACET 500 MCG/ML SYR OCTREOTIDE ACET 500 MCG/ML SYROCTREOTIDE ACET 500 MCG/ML SYROCTREOTIDE ACET 500 MCG/ML VL OCTREOTIDE ACET 500 MCG/ML VLOCTREOTIDE ACET 500 MCG/ML VLODEFSEY TABLETOFLOXACIN 0.3% EAR DROPSOFLOXACIN 0.3% EYE DROPOFLOXACIN 0.3% EYE DROPSOMEPRAZOLE DR 10 MG CAPSULEOMEPRAZOLE DR 20 MG CAPSULE

F4 71

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

OMEPRAZOLE DR 40 MG CAPSULEOMEPRAZOLE MAG DR 20 MG CAPONCE DAILY TABLETONCE DAILY WITH IRON TABLETONDANSETRON 4 MG/5 ML SOLUTION ONDANSETRON 4 MG/5 ML SOLUTIONONDANSETRON 4 MG/5 ML SOLUTIONONDANSETRON HCL 24 MG TABLETONDANSETRON HCL 4 MG TABLETONDANSETRON HCL 8 MG TABLETONDANSETRON ODT 4 MG TABLETONDANSETRON ODT 8 MG TABLETONE DAILY ESSENTIAL TABLETORAL SALINE LAXATIVE LIQUIDORSYTHIA-28 TABLETORTHO TRI-CYCLEN LO TABLETORTHO-NOVUM 7-7-7-28 TABLETOSELTAMIVIR 6 MG/ML SUSPENSIONOSELTAMIVIR PHOS 30 MG CAPSULEOSELTAMIVIR PHOS 45 MG CAPSULEOSELTAMIVIR PHOS 75 MG CAPSULEOXACILLIN 1 GM VIALOXACILLIN 2 GM VIALOXYBUTYNIN 5 MG TABLETOXYBUTYNIN 5 MG/5 ML SYRUPOXYCODONE HCL 10 MG TABLETOXYCODONE HCL 100 MG/5 ML CONCOXYCODONE HCL 15 MG TABLETOXYCODONE HCL 30 MG TABLETOXYCODONE HCL 5 MG CAPSULEOXYCODONE HCL 5 MG TABLET

F4 72

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

OXYCODONE HCL ER 10 MG TABLET OXYCODONE HCL ER 10 MG TABLETOXYCODONE HCL ER 10 MG TABLETOXYCODONE HCL ER 15 MG TABLET OXYCODONE HCL ER 15 MG TABLETOXYCODONE HCL ER 15 MG TABLETOXYCODONE HCL ER 20 MG TABLET OXYCODONE HCL ER 20 MG TABLETOXYCODONE HCL ER 20 MG TABLETOXYCODONE HCL ER 30 MG TABLET OXYCODONE HCL ER 30 MG TABLETOXYCODONE HCL ER 30 MG TABLETOXYCODONE HCL ER 40 MG TABLET OXYCODONE HCL ER 40 MG TABLETOXYCODONE HCL ER 40 MG TABLETOXYCODONE HCL ER 60 MG TABLET OXYCODONE HCL ER 60 MG TABLETOXYCODONE HCL ER 60 MG TABLETOXYCODONE HCL ER 80 MG TABLET OXYCODONE HCL ER 80 MG TABLETOXYCODONE HCL ER 80 MG TABLETOXYCODONE-ACETAMINOPHEN 2.5-32OXYCODONE-ACETAMINOPHEN 5-325OYSTER SHELL 500-VIT D3 200 PKOYSTER SHELL 500-VIT D3 200 TBOYSTER SHELL CALCIUM-VIT D TABOYSTERCAL-D 500 MG-400 UNIT TBPAIN RELIEF 160 MG/5 ML LIQUIDPAIN RELIEF 325 MG TABLETPAIN RELIEF 500 MG CAPLETPAIN RELIEF 500 MG CAPSULEPAIN RELIEF 500 MG GELCAPPAIN RELIEF 500 MG GELTABPAIN RELIEF 500 MG TABLETPAIN RELIEF ADULT 500 MG/15 MLPAIN RELIEF ER 650 MG CAPLETPAIN RELIEVER 325 MG TABLETPAIN RELIEVER 500 MG CAPLETPAIN RELIEVER 500 MG GELCAPPAIN RELIEVER 500 MG TABLETPAIN RELIEVER ER 650 MG CAPLETPAIN RELIEVING 10% CREAMPAIN-RELIEF CREAM

F4 73

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PANCREAZE DR 10,500 UNIT CAPPANCREAZE DR 16,800 UNIT CAPPANCREAZE DR 2,600 UNIT CAPPANCREAZE DR 21,000 UNIT CAPPANCREAZE DR 4,200 UNIT CAPPANCRELIPASE DR 5,000 UNIT CAPPANTOPRAZOLE SOD DR 20 MG TAB PANTOPRAZOLE SOD DR 20 MG TABPANTOPRAZOLE SOD DR 40 MG TAB PANTOPRAZOLE SOD DR 40 MG TABPANTOPRAZOLE SODIUM 40 MG VIAL PANTOPRAZOLE SODIUM 40 MG VIALPATADAY 0.2% EYE DROPS PATADAY 0.2% EYE DROPS PATADAY 0.2% EYE DROPSPATANOL 0.1% EYE DROPS PATANOL 0.1% EYE DROPS PATANOL 0.1% EYE DROPSPEDIA POLY-VITE DROPSPEDIA POLY-VITE WITH IRON 5 MGPEDIA POLY-VITE WITH IRON DROPPEDIA RELIEF COUGH-COLD LIQUIDPEDIA TRI-VITE DROPPEDIATRIC COUGH-COLD LIQUIDPEDIATRIC COUGH-COLD SYRUPPEDIATRIC ENEMAPEG 3350 ELECTROLYTE SOLNPEG 3350-ELECTROLYTE SOLUTIONPEG-3350 AND ELECTROLYTES SOLNPEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS 180 MCG/0.5 ML SYRINGEPEGASYS 180 MCG/ML VIAL PEGASYS 180 MCG/ML VIALPEGINTRON 120 MCG KIT PEGINTRON 120 MCG KITPEGINTRON 150 MCG KIT PEGINTRON 150 MCG KITPEGINTRON 50 MCG KIT PEGINTRON 50 MCG KITPEGINTRON 80 MCG KIT PEGINTRON 80 MCG KITPEGINTRON REDIPEN 120 MCG PEGINTRON REDIPEN 120 MCG

F4 74

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PEGINTRON REDIPEN 120 MCG 4PK PEGINTRON REDIPEN 120 MCG 4PKPEGINTRON REDIPEN 150 MCG PEGINTRON REDIPEN 150 MCGPEGINTRON REDIPEN 150 MCG 4PK PEGINTRON REDIPEN 150 MCG 4PKPEGINTRON REDIPEN 50 MCG PEGINTRON REDIPEN 50 MCGPEGINTRON REDIPEN 50 MCG 4PK PEGINTRON REDIPEN 50 MCG 4PKPEGINTRON REDIPEN 80 MCG PEGINTRON REDIPEN 80 MCGPEGINTRON REDIPEN 80 MCG 4PK PEGINTRON REDIPEN 80 MCG 4PKPENICILLIN VK 125 MG/5 ML SOLNPENICILLIN VK 250 MG TABLETPENICILLIN VK 250 MG/5 ML SOLNPENICILLIN VK 250 MG/5 ML SUSPENICILLIN VK 500 MG TABLETPENTASA 250 MG CAPSULEPENTASA 500 MG CAPSULEPENTOXIFYLLINE ER 400 MG TAB PENTOXIFYLLINE ER 400 MG TABPERMETHRIN 1% LOTIONPERMETHRIN 5% CREAMPERTZYE DR 16,000 UNIT CAPSULEPERTZYE DR 24,000 UNIT CAPSULEPERTZYE DR 4,000 UNIT CAPSULEPERTZYE DR 8,000 UNIT CAPSULEPHARM CHOICE ALCOHOL PREP PADSPHENAZOPYRIDINE 100 MG TABPHENAZOPYRIDINE 200 MG TABPHENAZOPYRIDINE 95 MG TABLETPHENOBARBITAL 100 MG TABLETPHENOBARBITAL 130 MG/ML VIALPHENOBARBITAL 15 MG TABLETPHENOBARBITAL 16.2 MG TABLET

F4 75

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PHENOBARBITAL 20 MG/5 ML ELIXPHENOBARBITAL 20 MG/5 ML SOLNPHENOBARBITAL 30 MG TABLETPHENOBARBITAL 32.4 MG TABLETPHENOBARBITAL 60 MG TABLETPHENOBARBITAL 64.8 MG TABLETPHENOBARBITAL 65 MG/ML VIALPHENOBARBITAL 97.2 MG TABLETPHENYLEPHRINE 10 MG/ML VIALPHENYLEPHRINE 100 MG/10 ML VLPHENYLEPHRINE 2.5% EYE DROPPHENYLEPHRINE 50 MG/5 ML VIALPHENYL-FREE 1 POWDERPHENYL-FREE 2 POWDERPHENYTOIN 100 MG/4 ML SUSPPHENYTOIN 125 MG/5 ML SUSPPHENYTOIN 50 MG INFATABPHENYTOIN 50 MG TABLET CHEWPHENYTOIN SOD EXT 100 MG CAPPHENYTOIN SOD EXT 200 MG CAPPHENYTOIN SOD EXT 300 MG CAPPHILITH 0.4-0.035 MG TABLETPHOSPHATE ORAL SALINE LAXATIVEPHYTONADIONE 10 MG/ML AMPUL PHYTONADIONE 10 MG/ML AMPULPHYTONADIONE 5 MG TABLET PHYTONADIONE 5 MG TABLETPILOCARPINE 1% EYE DROPSPILOCARPINE 2% EYE DROPSPILOCARPINE 4% EYE DROPSPIMTREA 28 DAY TABLET

F4 76

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PINK BISMUTH 262 MG/15 ML SUSPPINK BISMUTH CAPLETPINK BISMUTH MAX-STR SUSPPINK BISMUTH TABLET CHEWPIN-X 144 MG/ML (50 MG/ML BASEPIN-X 250 MG (BASE) TAB CHEWPIOGLITAZONE HCL 15 MG TABLETPIOGLITAZONE HCL 30 MG TABLETPIOGLITAZONE HCL 45 MG TABLETPIOGLITAZONE-GLIMEPIRIDE 30-2PIOGLITAZONE-GLIMEPIRIDE 30-4PIOGLITAZONE-METFORMIN 15-500PIOGLITAZONE-METFORMIN 15-850PIRMELLA 1-35 28 TABLETPIRMELLA 1-35-28 TABLETPIRMELLA 7-7-7-28 TABLETPIROXICAM 10 MG CAPSULEPIROXICAM 20 MG CAPSULEPLAIN NIACIN 250 MG TABLETPLAIN NIACIN 500 MG TABLETPLENVU POWDER PACKETSPNV 29-1 TABLETPNV OB+DHA COMBO PACKPNV-SELECT TABLETPNV-TOTAL SOFTGELPODOFILOX 0.5% TOPICAL SOLNPOLY VITAMIN-IRON CHEWABLE TABPOLYCIN EYE OINTMENTPOLYETHYLENE GLYCOL 3350 POWD

F4 77

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

POLYMYXIN B-TMP EYE DROPSPOLY-VI-FLOR 0.25 MG DROPSPOLY-VI-FLOR 0.25 MG TAB CHEWPOLY-VI-FLOR 0.5 MG TAB CHEWPOLY-VI-FLOR 1 MG TAB CHEWPOLY-VI-FLOR FS 0.25 MG FILMPOLY-VI-FLOR FS 0.5 MG FILMPOLY-VI-FLOR FS 1 MG FILM STRPPOLY-VI-FLOR WITH IRON 0.25 MGPOLY-VI-FLOR WITH IRON 0.5 MGPOLY-VI-SOL 0.5 ML ORAL SYRINGPOLY-VI-SOL DROPSPOLY-VI-SOL WITH IRON DROPSPOLY-VITA DROPSPOLY-VITA WITH IRON DROPSPOLY-VITAMIN DROPSPOLYVITAMIN W-IRON DROPSPOLYVITAMIN WITH IRON TAB CHEWPORTIA-28 TABLETPOTASSIUM CHLORIDE 20 MEQ/10 MPOTASSIUM CL 10 MEQ/100 ML SOLPOTASSIUM CL 10 MEQ/5 ML CONCPOTASSIUM CL 10 MEQ/50 ML SOLPOTASSIUM CL 10% (20 MEQ/15 MLPOTASSIUM CL 10% (40 MEQ/30 MLPOTASSIUM CL 2 MEQ/ML CONCPOTASSIUM CL 20 MEQ PACKETPOTASSIUM CL 20 MEQ/10 ML CONCPOTASSIUM CL 20 MEQ/100 ML SOL

F4 78

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

POTASSIUM CL 20 MEQ/100 ML-WATPOTASSIUM CL 20 MEQ/50 ML SOLPOTASSIUM CL 20% (40 MEQ/15 MLPOTASSIUM CL 30 MEQ/100 ML SOLPOTASSIUM CL 30 MEQ/15 ML CONCPOTASSIUM CL 40 MEQ/100 ML SOLPOTASSIUM CL 40 MEQ/20 ML CONCPOTASSIUM CL 60 MEQ/30 ML CONCPOTASSIUM CL CONCENTRATE 10 MEPOTASSIUM CL ER 10 MEQ CAPSULEPOTASSIUM CL ER 10 MEQ TABLETPOTASSIUM CL ER 20 MEQ TABLETPOTASSIUM CL ER 8 MEQ CAPSULEPOTASSIUM CL ER 8 MEQ TABLETPR BENZOYL PEROXIDE 7% WASHPR NATAL 430 EC COMBO PACKPRADAXA 110 MG CAPSULE PRADAXA 110 MG CAPSULE PRADAXA 110 MG CAPSULEPRADAXA 150 MG CAPSULE PRADAXA 150 MG CAPSULE PRADAXA 150 MG CAPSULEPRADAXA 75 MG CAPSULE PRADAXA 75 MG CAPSULE PRADAXA 75 MG CAPSULEPRAVASTATIN SODIUM 10 MG TABPRAVASTATIN SODIUM 20 MG TABPRAVASTATIN SODIUM 40 MG TABPRAVASTATIN SODIUM 80 MG TABPRAZOSIN 1 MG CAPSULEPRAZOSIN 2 MG CAPSULEPRAZOSIN 5 MG CAPSULEPREDNISOLONE 10 MG/5 ML SOLNPREDNISOLONE 15 MG/5 ML SOLNPREDNISOLONE 15 MG/5 ML SYRUP

F4 79

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PREDNISOLONE 20 MG/5 ML SOLNPREDNISOLONE 5 MG/5 ML SOLNPREDNISOLONE AC 1% EYE DROPPREDNISOLONE ODT 10 MG TABLETPREDNISOLONE ODT 15 MG TABLETPREDNISOLONE ODT 30 MG TABLETPREDNISOLONE SOD PH 25 MG/5 MLPREDNISONE 1 MG TABLETPREDNISONE 10 MG TAB DOSE PACKPREDNISONE 10 MG TABLETPREDNISONE 2.5 MG TABLETPREDNISONE 20 MG TABLETPREDNISONE 5 MG TAB DOSE PACKPREDNISONE 5 MG TABLETPREDNISONE 5 MG/5 ML SOLUTIONPREDNISONE 50 MG TABLETPREMARIN 0.3 MG TABLETPREMARIN 0.45 MG TABLETPREMARIN 0.625 MG TABLETPREMARIN 0.9 MG TABLETPREMARIN 1.25 MG TABLETPREMARIN 25 MG VIALPREMARIN VAGINAL CREAM-APPLPREMPHASE 0.625-5 MG TABLETPREMPRO 0.3 MG-1.5 MG TABLETPREMPRO 0.45-1.5 MG TABLETPREMPRO 0.625-2.5 MG TABLETPREMPRO 0.625-5 MG TABLETPRENATA CHEWABLE TABLET

F4 80

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PRENATE AM TABLETPRENATE CHEWABLE TABLETPRENATE DHA SOFTGELPRENATE ELITE TABLETPRENATE ENHANCE SOFTGELPRENATE ESSENTIAL SOFTGELPRENATE MINI SOFTGELPRENATE PIXIE SOFTGELPRENATE RESTORE SOFTGELPRENATE STAR TABLETPREP EASE ALCOHOL PADSPREPLUS CA-FE 27 MG-FA 1 MG TBPREVACID 15 MG SOLUTAB PREVACID 15 MG SOLUTABPREVACID 30 MG SOLUTAB PREVACID 30 MG SOLUTABPREVIFEM TABLETPREZCOBIX 800 MG-150 MG TABLETPREZISTA 75 MG TABLETPREZISTA 800 MG TABLETPRILOSEC OTC 20 MG TABLETPRILOSEC OTC 20.6 MG TABLETPRIMIDONE 250 MG TABLETPRIMIDONE 50 MG TABLETPROAIR HFA 90 MCG INHALERPROBENECID 500 MG TABLETPROCAINAMID 1,000 MG/10 ML SYRPROCAINAMIDE 1,000 MG/10 ML VLPROCAINAMIDE 1,000 MG/2 ML VLPROCAINAMIDE 500 MG/ML VIALPROCHLORPERAZINE 10 MG TAB

F4 81

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PROCHLORPERAZINE 25 MG SUPPPROCHLORPERAZINE 5 MG TABLETPROCTOZONE-HC 2.5% CREAMPROMETHAZINE 12.5 MG TABLETPROMETHAZINE 25 MG TABLETPROMETHAZINE 50 MG TABLETPROMETHAZINE 6.25 MG/5 ML SOLNPROPAFENONE HCL 150 MG TABLETPROPAFENONE HCL 225 MG TABPROPAFENONE HCL 300 MG TABPROPAFENONE HCL ER 225 MG CAPPROPAFENONE HCL ER 325 MG CAPPROPAFENONE HCL ER 425 MG CAPPROPANTHELINE 15 MG TABLETPROPRANOLOL 1 MG/ML VIALPROPRANOLOL 10 MG TABLETPROPRANOLOL 20 MG TABLETPROPRANOLOL 20 MG/5 ML SOLNPROPRANOLOL 40 MG TABLETPROPRANOLOL 40 MG/5 ML SOLNPROPRANOLOL 60 MG TABLETPROPRANOLOL 80 MG TABLETPROPRANOLOL ER 120 MG CAPSULEPROPRANOLOL ER 160 MG CAPSULEPROPRANOLOL ER 60 MG CAPSULEPROPRANOLOL ER 80 MG CAPSULEPROPRANOLOL-HYDROCHLOROTHIAZIDPROPYLTHIOURACIL 50 MG TABLETPROVENTIL HFA 90 MCG INHALER

F4 82

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

PSEUDOEPHED 30 MG/5 ML SOLNPSEUDOEPHEDRINE 30 MG TABLETPSEUDOEPHEDRINE 60 MG TABLETPSEUDOEPHEDRINE ER 120 MG TABPSYLLIUM CAPSULEPSYLLIUM SEED POWDERPULMICORT 180 MCG FLEXHALERPULMICORT 90 MCG FLEXHALERPYRAZINAMIDE 500 MG TABLETPYRIDOSTIGMINE 60 MG/5 ML SOLNPYRIDOSTIGMINE BR 30 MG TABLETPYRIDOSTIGMINE BR 60 MG TABLETPYRIDOSTIGMINE ER 180 MG TABQ-DRYL 12.5 MG/5 ML LIQUIDQ-DRYL 25 MG CAPSULEQ-PAP 160 MG/5 ML LIQUIDQ-PAP 160 MG/5 ML SOLUTIONQ-PAP 325 MG TABLETQ-PAP 80 MG/0.8 ML DROPSQ-PAP EX-STR 500 MG TABLETQ-TUSSIN DM SYRUPQUASENSE 0.15-0.03 MG TABLETQUINAPRIL 10 MG TABLETQUINAPRIL 20 MG TABLETQUINAPRIL 40 MG TABLETQUINAPRIL 5 MG TABLETQUINIDINE SULF ER 300 MG TABQUINIDINE SULFATE 200 MG TABQUINIDINE SULFATE 300 MG TAB

F4 83

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

QVAR 40 MCG ORAL INHALERQVAR 80 MCG ORAL INHALERQVAR REDIHALER 40 MCGQVAR REDIHALER 80 MCGRABEPRAZOLE DR 10 MG SPRNKL CP RABEPRAZOLE DR 10 MG SPRNKL CPRABEPRAZOLE SOD DR 20 MG TAB RABEPRAZOLE SOD DR 20 MG TABRAJANI 28 TABLETRALOXIFENE HCL 60 MG TABLET RALOXIFENE HCL 60 MG TABLETRALOXIFENE HCL 60 MG TABLETRAMIPRIL 1.25 MG CAPSULERAMIPRIL 10 MG CAPSULERAMIPRIL 2.5 MG CAPSULERAMIPRIL 5 MG CAPSULERANITIDINE 15 MG/ML SYRUPRANITIDINE 150 MG TABLETRANITIDINE 150 MG/10 ML SYRUPRANITIDINE 300 MG TABLETRANITIDINE 75 MG TABLETRANITIDINE HCL 150 MG/6 ML VIARANITIDINE HCL 50 MG/2 ML VIALREBIF 22 MCG/0.5 ML SYRINGE REBIF 22 MCG/0.5 ML SYRINGEREBIF 44 MCG/0.5 ML SYRINGE REBIF 44 MCG/0.5 ML SYRINGEREBIF REBIDOSE 22 MCG/0.5 ML REBIF REBIDOSE 22 MCG/0.5 MLREBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE 44 MCG/0.5 MLREBIF REBIDOSE TITRATION PACK REBIF REBIDOSE TITRATION PACKREBIF TITRATION PACK REBIF TITRATION PACKRECLIPSEN 28 DAY TABLETRECOMBINATE 1,241-1,800 UNIT V RECOMBINATE 1,241-1,800 UNIT VRECOMBINATE 1,801-2,400 UNIT V RECOMBINATE 1,801-2,400 UNIT VRECOMBINATE 220-400 UNIT VIAL RECOMBINATE 220-400 UNIT VIAL

F4 84

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

RECOMBINATE 401-800 UNIT VIAL RECOMBINATE 401-800 UNIT VIALRECOMBINATE 801-1,240 UNIT VL RECOMBINATE 801-1,240 UNIT VLREESE'S PINWORM 144 MG/ML SUSPREGULOID 3.4 G/12 G POWDERREGULOID 3.4 G/7 G POWDERREGULOID CAPSULEREGULOID LAXATIVE POWDERREGULOID POWDERRELENZA 5 MG DISKHALERRELION ALCOHOL 70% SWABSRELION KETONE TEST STRIPRELION NOVOLIN 70-30 FLEXPENRELION NOVOLIN 70-30 VIALRELION NOVOLIN N 100 UNIT/MLRELION NOVOLIN R 100 UNIT/MLREPAGLINIDE 0.5 MG TABLET REPAGLINIDE 0.5 MG TABLET REPAGLINIDE 0.5 MG TABLETREPAGLINIDE 1 MG TABLET REPAGLINIDE 1 MG TABLET REPAGLINIDE 1 MG TABLETREPAGLINIDE 2 MG TABLET REPAGLINIDE 2 MG TABLET REPAGLINIDE 2 MG TABLETREPATHA 140 MG/ML SURECLICK REPATHA 140 MG/ML SURECLICKREPATHA 140 MG/ML SYRINGE REPATHA 140 MG/ML SYRINGERESERPINE 0.1 MG TABLETRESERPINE 0.25 MG TABLETRIBASPHERE 200 MG CAPSULE RIBASPHERE 200 MG CAPSULERIBASPHERE 200 MG TABLET RIBASPHERE 200 MG TABLETRIBAVIRIN 200 MG TABLET RIBAVIRIN 200 MG TABLETRIBAVIRIN 6 GM INHALATION VIAL RIBAVIRIN 6 GM INHALATION VIALRIFABUTIN 150 MG CAPSULERIFAMPIN 150 MG CAPSULERIFAMPIN 300 MG CAPSULE

F4 85

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

RIFAMPIN IV 600 MG VIALRILUZOLE 50 MG TABLET RILUZOLE 50 MG TABLETRISEDRONATE SOD DR 35 MG TABRISEDRONATE SODIUM 150 MG TABRISEDRONATE SODIUM 30 MG TABRISEDRONATE SODIUM 30 MG TABLERISEDRONATE SODIUM 35 MG TABRISEDRONATE SODIUM 35 MG TABLERISEDRONATE SODIUM 5 MG TABLETRITONAVIR 100 MG TABLETRITONAVIR ORAL TABLET 100 MGRI-TUSSIN DM SYRUPRIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE 1.5 MG CAPSULERIVASTIGMINE 13.3 MG/24HR PTCH RIVASTIGMINE 13.3 MG/24HR PTCHRIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE 3 MG CAPSULERIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE 4.5 MG CAPSULERIVASTIGMINE 4.6 MG/24HR PATCH RIVASTIGMINE 4.6 MG/24HR PATCHRIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE 6 MG CAPSULERIVASTIGMINE 9.5 MG/24HR PATCH RIVASTIGMINE 9.5 MG/24HR PATCHRIZATRIPTAN 10 MG ODT RIZATRIPTAN 10 MG ODTRIZATRIPTAN 10 MG TABLET RIZATRIPTAN 10 MG TABLETRIZATRIPTAN 5 MG ODT RIZATRIPTAN 5 MG ODTRIZATRIPTAN 5 MG TABLET RIZATRIPTAN 5 MG TABLETROBAFEN 100 MG/5 ML SYRUPROBAFEN 200 MG/10 ML SYRUPROBAFEN DM CGH-CHEST CONG SYRPROBAFEN DM COUGH LIQUIDROBAFEN DM COUGH SYRUPROBAFEN-DM SYRUP

F4 86

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ROPINIROLE HCL 0.25 MG TABLET ROPINIROLE HCL 0.25 MG TABLETROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL 0.5 MG TABLETROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL 1 MG TABLETROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL 2 MG TABLETROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL 3 MG TABLETROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL 4 MG TABLETROPINIROLE HCL 5 MG TABLET ROPINIROLE HCL 5 MG TABLETROPINIROLE HCL ER 12 MG TABLET ROPINIROLE HCL ER 12 MG TABLETROPINIROLE HCL ER 2 MG TABLET ROPINIROLE HCL ER 2 MG TABLETROPINIROLE HCL ER 4 MG TABLET ROPINIROLE HCL ER 4 MG TABLETROPINIROLE HCL ER 6 MG TABLET ROPINIROLE HCL ER 6 MG TABLETROPINIROLE HCL ER 8 MG TABLET ROPINIROLE HCL ER 8 MG TABLETROSUVASTATIN CALCIUM 10 MG TABROSUVASTATIN CALCIUM 20 MG TABROSUVASTATIN CALCIUM 40 MG TABROSUVASTATIN CALCIUM 5 MG TABROXICET 5-325 ORAL SOLUTIONSALSALATE 500 MG TABLETSALSALATE 750 MG TABLETSANTYL OINTMENTSAPS ALCOHOL 70% PREP PADSSAPS CARE ALCOHOL PREP PADSSAVELLA 100 MG TABLET SAVELLA 100 MG TABLETSAVELLA 12.5 MG TABLET SAVELLA 12.5 MG TABLETSAVELLA 25 MG TABLET SAVELLA 25 MG TABLETSAVELLA 50 MG TABLET SAVELLA 50 MG TABLETSAVELLA TITRATION PACK SAVELLA TITRATION PACKSEASONIQUE 0.15-0.03-0.01 TABSELECT-OB + DHA PACK

F4 87

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

SELECT-OB CHEWABLE CAPLETSELEGILINE HCL 5 MG CAPSULESELEGILINE HCL 5 MG TABLETSEMGLEESE-NATAL 19 CHEWABLE TABLETSENNA-DOCUSATE SODIUM TABLETSEREVENT DISKUS 50 MCG SEREVENT DISKUS 50 MCG SEREVENT DISKUS 50 MCGSETLAKIN 0.15 MG-0.03 MG TABSF 1.1% GELSHAROBEL 0.35 MG TABLETSILADRYL 12.5 MG/5 ML LIQUIDSILDENAFIL 20 MG TABLET SILDENAFIL 20 MG TABLETSILTUSSIN DM COUGH SYRUPSILTUSSIN DM DAS LIQUIDSILTUSSIN SA 100 MG/5 ML LIQSILTUSSIN SA 100 MG/5 ML SYRSILTUSSIN SA 200 MG/10 ML LIQSILTUSSIN SA 300 MG/15 ML LIQSILVER SULFADIAZINE 1% CREAMSIMCOR 1,000-20 MG TABLETSIMCOR 1,000-40 MG TABLETSIMCOR 500-20 MG TABLETSIMCOR 500-40 MG TABLETSIMCOR 750-20 MG TABLETSIMLIYA 28 DAY TABLETSIMPESSE 0.15-0.03-0.01 MG TABSIMVASTATIN 10 MG TABLETSIMVASTATIN 20 MG TABLETSIMVASTATIN 20 MG/5 ML SUSP

F4 88

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

SIMVASTATIN 40 MG TABLETSIMVASTATIN 5 MG TABLETSIMVASTATIN 80 MG TABLET SIMVASTATIN 80 MG TABLETSIROLIMUS 0.5 MG TABLETSIROLIMUS 1 MG TABLETSIROLIMUS 1 MG/ML SOLUTIONSIROLIMUS 2 MG TABLETSOBA ASPIRIN 325 MG TABLETSOD CITRATE-CITRIC ACID SOLNSOD POLYSTYREN SULF 15 G/60 MLSOD SULFACETAM 10% CLNSNG GELSOD SULFACETAMIDE 10% SHAMPOOSODIUM FLUORIDE 0.25 (0.55) MGSODIUM FLUORIDE 0.5 MG/ML DROPSODIUM FLUORIDE 1.1% CREAMSODIUM FLUORIDE 1.1% GELSODIUM POLYSTYRENE SULF POWDERSODIUM SULFACETAMIDE 10% LOTSODIUM SULFACETAMIDE 10% LOTNSODIUM SULFACETAMIDE 10% WASHSOFOSBUVIR-VELPATASVIR 400-100 SOFOSBUVIR-VELPATASVIR 400-100SOTALOL 120 MG TABLETSOTALOL 160 MG TABLETSOTALOL 240 MG TABLETSOTALOL 80 MG TABLETSOTALOL AF 120 MG TABLETSOTALOL AF 160 MG TABLETSOTALOL AF 80 MG TABLETSOTALOL HCL 150 MG/10 ML VIAL

F4 89

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

SPIRIVA 18 MCG CP-HANDIHALERSPIRIVA RESPIMAT 1.25 MCG INHSPIRIVA RESPIMAT 2.5 MCG INHSPIRONOLACTONE 100 MG TABLETSPIRONOLACTONE 25 MG TABLETSPIRONOLACTONE 50 MG TABLETSPIRONOLACTONE-HYDROCHLOROTHIASPORANOX 10 MG/ML SOLUTION SPORANOX 10 MG/ML SOLUTIONSPRINTEC 28 DAY TABLETSPS 15 GM/60 ML SUSPENSIONSPS 30 GM/120 ML ENEMASPS 50 GM/200 ML ENEMASRONYX 0.10-0.02 MG TABLETSTAVUDINE ORAL CAPSULE 15 MGSTAVUDINE ORAL CAPSULE 20 MGSTAVUDINE ORAL CAPSULE 30 MGSTAVUDINE ORAL CAPSULE 40 MGSTIMATE 1.5 MG/ML NASAL SPRAY STIMATE 1.5 MG/ML NASAL SPRAYSTIOLTO RESPIMAT INHAL SPRAYSTRIBILD TABLETSTRIVERDI RESPIMAT INHAL SPRAY STRIVERDI RESPIMAT INHAL SPRAYSTRIVERDI RESPIMAT INHAL SPRAYSTROVITE FORTE CAPLETSTROVITE ONE CAPLETSUCRALFATE 1 GM TABLETSUCRALFATE 1 GM/10 ML SUSP SUCRALFATE 1 GM/10 ML SUSPSUCRALFATE 1 GM/10 ML SUSPSUDOGEST 30 MG TABLETSUDOGEST 60 MG TABLETSULFACETAMIDE 10% EYE DROPSSULFACETAMIDE 10% EYE OINTMENT

F4 90

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

SULFACETAMIDE SOD 10% TOP SUSPSULFADIAZINE 500 MG TABLETSULFAMETHOXAZOLE-TMP DS TABLETSULFAMETHOXAZOLE-TMP SS TABLETSULFAMETHOXAZOLE-TMP SUSPSULFASALAZINE 500 MG TABLETSULF-PRED 10-0.23% EYE DROPSSULF-PRED 10-0.25% EYE DROPSSULINDAC 150 MG TABLETSULINDAC 200 MG TABLETSUMATRIPTAN 20 MG NASAL SPRAYSUMATRIPTAN 4 MG/0.5 ML CARTSUMATRIPTAN 4 MG/0.5 ML INJECTSUMATRIPTAN 5 MG NASAL SPRAYSUMATRIPTAN 6 MG/0.5 ML INJECTSUMATRIPTAN 6 MG/0.5 ML REFILLSUMATRIPTAN 6 MG/0.5 ML SYRNGSUMATRIPTAN 6 MG/0.5 ML VIALSUMATRIPTAN SUCC 100 MG TABLETSUMATRIPTAN SUCC 25 MG TABLETSUMATRIPTAN SUCC 50 MG TABLETSUMATRIPTAN-NAPROXEN 85-500 MGSUPRAX 400 MG CAPSULESYEDA 28 TABLETSYMBICORT 160-4.5 MCG INHALER SYMBICORT 160-4.5 MCG INHALERSYMBICORT 160-4.5 MCG INHALERSYMBICORT 80-4.5 MCG INHALER SYMBICORT 80-4.5 MCG INHALERSYMBICORT 80-4.5 MCG INHALERSYMTUZA 800-150-200-10 MG TABSYNAGIS 100 MG/1 ML VIAL SYNAGIS 100 MG/1 ML VIALSYNAGIS 50 MG/0.5 ML VIAL SYNAGIS 50 MG/0.5 ML VIAL

F4 91

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

SYNAREL 2 MG/ML NASAL SPRAY SYNAREL 2 MG/ML NASAL SPRAYSYNAREL 2 MG/ML NASAL SPRAYTAB TUSSIN DM 400-20 MG TABLETTABLOID 40 MG TABLETTACROLIMUS 0.03% OINTMENT TACROLIMUS 0.03% OINTMENTTACROLIMUS 0.1% OINTMENT TACROLIMUS 0.1% OINTMENTTACROLIMUS 0.5 MG CAPSULE TACROLIMUS 0.5 MG CAPSULETACROLIMUS 1 MG CAPSULE TACROLIMUS 1 MG CAPSULETACROLIMUS 5 MG CAPSULE TACROLIMUS 5 MG CAPSULETAMIFLU 30 MG CAPSULETAMIFLU 45 MG CAPSULETAMIFLU 6 MG/ML SUSPENSIONTAMIFLU 75 MG CAPSULETAMOXIFEN 10 MG TABLETTAMOXIFEN 20 MG TABLETTAMSULOSIN HCL 0.4 MG CAPSULETARCEVA 100 MG TABLETTARCEVA 150 MG TABLETTARCEVA 25 MG TABLETTARINA 24 FE 1 MG-20 MCG TABTARINA FE 1-20 EQ TABLETTARINA FE 1-20 TABLETTAZTIA XT 120 MG CAPSULETAZTIA XT 180 MG CAPSULETAZTIA XT 240 MG CAPSULETAZTIA XT 300 MG CAPSULETAZTIA XT 360 MG CAPSULETECFIDERA DR 120 MG CAPSULE TECFIDERA DR 120 MG CAPSULETECFIDERA DR 240 MG CAPSULE TECFIDERA DR 240 MG CAPSULETECFIDERA STARTER PACK TECFIDERA STARTER PACK

F4 92

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

TENOFOVIR DISOPROXIL FUMARATETERAZOSIN 1 MG CAPSULETERAZOSIN 10 MG CAPSULETERAZOSIN 2 MG CAPSULETERAZOSIN 5 MG CAPSULETERBINAFINE 1% CREAMTERBINAFINE HCL 250 MG TABLETTESTIM 1% (50 MG) GEL TESTIM 1% (50 MG) GELTESTOSTERON CYP 1,000 MG/10 ML TESTOSTERON CYP 1,000 MG/10 MLTESTOSTERON CYP 2,000 MG/10 ML TESTOSTERON CYP 2,000 MG/10 MLTESTOSTERONE 1.62% (2.5 G) PKT TESTOSTERONE 1.62% (2.5 G) PKTTESTOSTERONE 1.62% GEL PUMP TESTOSTERONE 1.62% GEL PUMPTESTOSTERONE 1.62%(1.25 G) PKT TESTOSTERONE 1.62%(1.25 G) PKTTESTOSTERONE 10 MG GEL PUMP TESTOSTERONE 10 MG GEL PUMPTESTOSTERONE 12.5 MG/1.25 GRAM TESTOSTERONE 12.5 MG/1.25 GRAMTESTOSTERONE 25 MG/2.5 GM PKT TESTOSTERONE 25 MG/2.5 GM PKTTESTOSTERONE 30 MG/1.5 ML PUMP TESTOSTERONE 30 MG/1.5 ML PUMPTESTOSTERONE 50 MG/5 GRAM GEL TESTOSTERONE 50 MG/5 GRAM GELTESTOSTERONE 50 MG/5 GRAM PKT TESTOSTERONE 50 MG/5 GRAM PKTTESTOSTERONE CYP 100 MG/ML TESTOSTERONE CYP 100 MG/MLTESTOSTERONE CYP 200 MG/ML TESTOSTERONE CYP 200 MG/MLTESTOSTERONE CYPIONATE 1,000 M TESTOSTERONE CYPIONATE 1,000 MTESTOSTERONE CYPIONATE 250 MG/ TESTOSTERONE CYPIONATE 250 MG/TESTOSTERONE CYPIONATE 500 MG/ TESTOSTERONE CYPIONATE 500 MG/TESTOSTERONE CYPIONATE 6,000 M TESTOSTERONE CYPIONATE 6,000 MTETRACYCLINE 250 MG CAPSULETETRACYCLINE 500 MG CAPSULETHEO-24 ER 100 MG CAPSULETHEO-24 ER 200 MG CAPSULE

F4 93

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

THEO-24 ER 300 MG CAPSULETHEO-24 ER 400 MG CAPSULETHEOPHYLLINE 80 MG/15 ML SOLNTHEOPHYLLINE ER 100 MG TABLETTHEOPHYLLINE ER 200 MG TABLETTHEOPHYLLINE ER 300 MG TABTHEOPHYLLINE ER 400 MG TABLETTHEOPHYLLINE ER 450 MG TABTHEOPHYLLINE ER 600 MG TABLETTHERA CAPLETTHIAMINE 100 MG TABLETTHIAMINE 200 MG/2 ML VIALTHIAMINE 250 MG TABLETTHIAMINE 500 MG TABLETTHROMBATE III 500 UNIT VIAL THROMBATE III 500 UNIT VIALTHROMBI-GEL SIZE 10 THROMBI-GEL SIZE 10THROMBI-GEL SIZE 100 THROMBI-GEL SIZE 100THROMBI-GEL SIZE 40 THROMBI-GEL SIZE 40THROMBIN-JMI 20,000 UNITS PUMP THROMBIN-JMI 20,000 UNITS PUMPTHROMBIN-JMI 20,000 UNITS SYR THROMBIN-JMI 20,000 UNITS SYRTHROMBIN-JMI 20,000 UNITS VIAL THROMBIN-JMI 20,000 UNITS VIALTHROMBIN-JMI 5,000 UNIT EPISTA THROMBIN-JMI 5,000 UNIT EPISTATHROMBIN-JMI 5,000 UNITS SYR THROMBIN-JMI 5,000 UNITS SYRTHROMBIN-JMI 5,000 UNITS VIAL THROMBIN-JMI 5,000 UNITS VIALTILIA FE 28 TABLETTIMOLOL 0.25% GEL-SOLUTIONTIMOLOL 0.25% GFS GEL-SOLUTIONTIMOLOL 0.5% EYE DROPTIMOLOL 0.5% GEL-SOLUTION

F4 94

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

TIMOLOL 0.5% GFS GEL-SOLUTIONTIMOLOL MALEATE 0.25% EYE DROPTIMOLOL MALEATE 0.5% EYE DROPSTIMOLOL MALEATE 10 MG TABLETTIMOLOL MALEATE 20 MG TABLETTIMOLOL MALEATE 5 MG TABLETTIVICAY 10 MG TABLETTIVICAY 25 MG TABLETTIVICAY 50 MG TABLETTL FOLATE TABLETTOBAKIENT CAPSULETOBRAMYCIN-DEXAMETH OPHTH SUSPTOLTERODINE TART ER 2 MG CAP TOLTERODINE TART ER 2 MG CAPTOLTERODINE TART ER 4 MG CAP TOLTERODINE TART ER 4 MG CAPTOLTERODINE TARTRATE 1 MG TAB TOLTERODINE TARTRATE 1 MG TABTOLTERODINE TARTRATE 2 MG TAB TOLTERODINE TARTRATE 2 MG TABTOUJEO MAX SOLOSTR 300 UNIT/MLTOUJEO SOLOSTAR 300 UNIT/MLTOVIAZ ER 4 MG TABLET TOVIAZ ER 4 MG TABLETTOVIAZ ER 8 MG TABLET TOVIAZ ER 8 MG TABLETTRAMADOL HCL 50 MG TABLETTRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER 100 MG TABLETTRAMADOL HCL ER 100 MG TABLETTRAMADOL HCL ER 200 MG TABLET TRAMADOL HCL ER 200 MG TABLETTRAMADOL HCL ER 200 MG TABLETTRAMADOL HCL ER 300 MG TABLET TRAMADOL HCL ER 300 MG TABLETTRAMADOL HCL ER 300 MG TABLETTRAMADOL-ACETAMINOPHEN 37.5-32TRECATOR 250 MG TABLETTRETINOIN 0.01% GELTRETINOIN 0.025% CREAMTRETINOIN 0.025% GEL

F4 95

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

TRETINOIN 0.05% CREAMTRETINOIN 0.05% GELTRETINOIN 0.1% CREAMTREXIMET 10-60 MG TABLETTREXIMET 85-500 MG TABLETTRI FEMYNOR 28 TABLETTRIAMCINOLONE 0.025% CREAMTRIAMCINOLONE 0.025% LOTIONTRIAMCINOLONE 0.025% OINTTRIAMCINOLONE 0.05% OINTMENTTRIAMCINOLONE 0.1% CREAMTRIAMCINOLONE 0.1% LOTIONTRIAMCINOLONE 0.1% OINTMENTTRIAMCINOLONE 0.1% PASTETRIAMCINOLONE 0.147 MG/G SPRAYTRIAMCINOLONE 0.5% CREAMTRIAMCINOLONE 0.5% OINTMENTTRIAMCINOLONE 55 MCG NASAL SPRTRIAMCINOLONE ACET 200 MG/5 MLTRIAMCINOLONE ACET 40 MG/ML VLTRIAMCINOLONE ACET 400 MG/10 MTRIAMTERENE-HYDROCHLOROTHIAZIDTRI-ESTARYLLA TABLETTRIFLURIDINE 1% EYE DROPSTRI-LEGEST FE-28 DAY TABLETTRI-LINYAH TABLETTRI-LO-ESTARYLLA TABLETTRI-LO-MARZIA TABLETTRI-LO-MILI TABLET

F4 96

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

TRI-LO-SPRINTEC TABLETTRIMETHOPRIM 100 MG TABLETTRI-MILI 28 TABLETTRINATAL RX 1 TABLETTRINESSA TABLETTRI-PREVIFEM TABLETTRI-SPRINTEC TABLETTRIUMEQ 600-50-300 MG TABLETTRI-VI-FLOR 0.25 MG DROPSTRI-VI-FLOR 0.5 MG DROPSTRI-VI-FLORO 0.25 MG/ML DROPTRI-VI-FLORO 0.5 MG/ML DROPTRI-VITA DROPSTRI-VITAMIN DROPSTRI-VITE-FLUORIDE 0.25 MG/MLTRI-VITE-FLUORIDE 0.5 MG/MLTRI-VIT-FLUOR 0.25 MG/ML DROPTRI-VIT-FLUOR 0.5 MG/ML DROPTRI-VIT-FLUOR-IRON 0.25 MG/MLTRIVORA-28 TABLETTRI-VYLIBRA 28 TABLETTRI-VYLIBRA LO TABLETTRUEPLUS KETONE TEST STRIPTRULICITY TRULICITYTRUSTEX CONDOMTRUSTEX LATEX CONDOMTRUSTEX-RIA CONDOMTUDORZA PRESSAIR 400 MCG INH TUDORZA PRESSAIR 400 MCG INHTUDORZA PRESSAIR 400 MCG INHTUDORZA PRESSAIR 400 MCG INHAL TUDORZA PRESSAIR 400 MCG INHALTUDORZA PRESSAIR 400 MCG INHAL

F4 97

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

TULANA 0.35 MG TABLETTUSSIN 100 MG/5 ML SYRUPTUSSIN CHEST CONGESTION LIQUIDTUSSIN CHEST CONGESTION SYRUPTUSSIN COUGH SYRUPTUSSIN COUGH-CHEST CONGEST LIQTUSSIN DM 400-20 MG TABLETTUSSIN DM 400-20 MG/20 ML LIQTUSSIN DM CLEARTUSSIN DM CLEAR SYRUPTUSSIN DM COUGH & CHEST SYRUPTUSSIN DM COUGH SYRUPTUSSIN DM LIQUIDTUSSIN DM MAX LIQUIDTUSSIN DM SYRUPTUSSIN HONEY SYRUPTUSSIN MUCUS-CONG 200 MG/10TYDEMY TABLETULTRESA DR 13,800 UNIT CAPSULEULTRESA DR 20,700 UNIT CAPSULEULTRESA DR 23,000 UNIT CAPSULEUREA 10% CREAMUREA 20% CREAMUREA 39% CREAMUREA 40% CREAMUREA 40% GELUREA 41% CREAMUREA 45% CREAMUREA 45% NAIL GEL

F4 98

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

UREA 47% CREAMUREA 50% CREAMVALSARTAN 160 MG TABLET VALSARTAN 160 MG TABLETVALSARTAN 320 MG TABLET VALSARTAN 320 MG TABLETVALSARTAN 40 MG TABLET VALSARTAN 40 MG TABLETVALSARTAN 80 MG TABLET VALSARTAN 80 MG TABLETVALSARTAN-HYDROCHLOROTHIAZIDEVELIVET 28 DAY TABLETVENTOLIN HFA 90 MCG INHALERVERAPAMIL 120 MG TABLETVERAPAMIL 40 MG TABLETVERAPAMIL 80 MG TABLETVERAPAMIL ER 120 MG TABLETVERAPAMIL ER 180 MG TABLETVERAPAMIL ER 240 MG TABLETVESTURA 3 MG-0.02 MG TABLETVIC-FORTE CAPSULEVICTOZA 2-PAK 18 MG/3 ML PEN VICTOZA 2-PAK 18 MG/3 ML PENVICTOZA 2-PAK 18 MG/3 ML PENVICTOZA 3-PAK 18 MG/3 ML PEN VICTOZA 3-PAK 18 MG/3 ML PENVICTOZA 3-PAK 18 MG/3 ML PENVIENVA-28 TABLETVIGAMOX 0.5% EYE DROPSVINATE ONE TABLETVINATE-M TABLETVIOKACE 10,440-39,150 UNITS TBVIOKACE 20,880-78,300 UNITS TBVIORELE 28 DAY TABLETVIRT-PN DHA SOFTGELVIT A,C,D-FLUORIDE 0.25 MG/MLVIT A,C,D-FLUORIDE 0.5 MG/ML

F4 99

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

VIT A,D,C-FLUORIDE 0.25 MG/MLVITAFOL NANO TABLETVITAFOL ULTRA SOFTGELVITAFOL-OB CAPLETVITAFOL-OB+DHA COMBO PACKVITAMIN A & D CAPSULEVITAMIN AND MINERALS TABLETVITAMIN B-1 100 MG TABLETVITAMIN B-1 250 MG TABLETVITAMIN B12 1,000 MCG TAB SA VITAMIN B12 1,000 MCG TAB SAVITAMIN B-12 1,000 MCG TAB SA VITAMIN B-12 1,000 MCG TAB SAVITAMIN B-12 1,000 MCG TAB SL VITAMIN B-12 1,000 MCG TAB SLVITAMIN B-12 1,000 MCG TABLETVITAMIN B-12 2,500 MCG TAB SL VITAMIN B-12 2,500 MCG TAB SLVITAMIN B-12 3,000 MCG TAB SL VITAMIN B-12 3,000 MCG TAB SLVITAMIN B-12 5,000 MCG ODT VITAMIN B-12 5,000 MCG ODTVITAMIN D3 1,000 UNIT SOFTGELVITAMIN D3 10,000 UNIT CAPSULEVITAMIN D3 125 MCG (5000 UNIT)VITAMIN D3 125 MCG CAPSULEVITAMIN D3 2,000 UNIT SOFTGELVITAMIN D3 25 MCG (1,000 UNIT)VITAMIN D3 400 UNIT SOFTGELVITAMIN D3 5,000 UNIT CAPSULEVITAMIN D3 5,000 UNIT SOFTGELVITAMIN D3 50 MCG (2,000 UNIT)VITAMIN D3 50,000 UNIT CAPSULEVITAMIN D3-ALOE 1,000 UNIT TABVITAMIN K 100 MCG TABLET VITAMIN K 100 MCG TABLET

F4 100

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

VITAMIN K-1 500 MCG TABLET SL VITAMIN K-1 500 MCG TABLET SLVITAMINS A-D-E TABLETVYFEMLA 28 TABLETVYLIBRA 28 TABLETVYTORIN 10-10 MG TABLET VYTORIN 10-10 MG TABLET VYTORIN 10-10 MG TABLETVYTORIN 10-20 MG TABLET VYTORIN 10-20 MG TABLET VYTORIN 10-20 MG TABLETVYTORIN 10-40 MG TABLET VYTORIN 10-40 MG TABLET VYTORIN 10-40 MG TABLETVYTORIN 10-80 MG TABLET VYTORIN 10-80 MG TABLET VYTORIN 10-80 MG TABLETWARFARIN SODIUM 1 MG TABLETWARFARIN SODIUM 10 MG TABLETWARFARIN SODIUM 2 MG TABLETWARFARIN SODIUM 2.5 MG TABLETWARFARIN SODIUM 3 MG TABLETWARFARIN SODIUM 4 MG TABLETWARFARIN SODIUM 5 MG TABLETWARFARIN SODIUM 6 MG TABLETWARFARIN SODIUM 7.5 MG TABLETWELLESSE B-12 1,000 MCG/ML SL WELLESSE B-12 1,000 MCG/ML SLWERA 0.5/0.035 MG 28 TABLETWIXELA 100-50 INHUB WIXELA 100-50 INHUB WIXELA 100-50 INHUBWIXELA 250-50 INHUB WIXELA 250-50 INHUB WIXELA 250-50 INHUBWIXELA 500-50 INHUB WIXELA 500-50 INHUB WIXELA 500-50 INHUBWOMEN'S 50 PLUS DAILY FORMULAWYMZYA FE CHEWABLE TABLETXULANE PATCHYASMIN 28 TABLETYAZ 28 TABLETZADITOR 0.025% (0.035%) DROPSZAFEMY PATCH

F4 101

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ZARAH TABLETZATEAN-PN DHA CAPSULEZATEAN-PN PLUS SOFTGELZENCHENT 0.4 MG-35 MCG TABLETZENCHENT FE TABLET CHEWABLEZENPEP DR 10,000 UNIT CAPSULEZENPEP DR 15,000 UNIT CAPSULEZENPEP DR 20,000 UNIT CAPSULEZENPEP DR 25,000 UNIT CAPSULEZENPEP DR 3,000 UNIT CAPSULEZENPEP DR 40,000 UNIT CAPSULEZENPEP DR 5,000 UNIT CAPSULEZEOSA CHEWABLE TABLETZEPATIER 50-100 MG TABLET ZEPATIER 50-100 MG TABLETZETIA 10 MG TABLET ZETIA 10 MG TABLETZIDOVUDINE 50 MG/5 ML SYRUPZIDOVUDINE ORAL CAPSULE 100 MGZIDOVUDINE ORAL TABLET 300 MGZOLMITRIPTAN 2.5 MG ODT ZOLMITRIPTAN 2.5 MG ODTZOLMITRIPTAN 2.5 MG TABLET ZOLMITRIPTAN 2.5 MG TABLETZOLMITRIPTAN 5 MG ODT ZOLMITRIPTAN 5 MG ODTZOLMITRIPTAN 5 MG TABLET ZOLMITRIPTAN 5 MG TABLETZOVIA 1-35E TABLETZOVIA 1-50E TABLETZOVIRAX 200 MG CAPSULE ZOVIRAX 200 MG CAPSULEZOVIRAX 200 MG/5 ML SUSP ZOVIRAX 200 MG/5 ML SUSPZOVIRAX 400 MG TABLET ZOVIRAX 400 MG TABLETZOVIRAX 5% CREAM ZOVIRAX 5% CREAMZOVIRAX 5% OINTMENT ZOVIRAX 5% OINTMENT

F4 102

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

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

ZOVIRAX 800 MG TABLET ZOVIRAX 800 MG TABLETZUMANDIMINE 3 MG-0.03 MG TAB

F4 103

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 104

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

ADVAIR HFA 115-21 MCG INHALER

F4 105

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

ADVAIR HFA 230-21 MCG INHALER

F4 106

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 107

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 108

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

ANORO ELLIPTA 62.5-25 MCG INH

F4 109

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 110

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 111

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 112

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

AZELASTINE 0.1% (137 MCG) SPRY

F4 113

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 114

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 115

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

BRIMONIDINE TARTRATE 0.15% DRP

F4 116

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

CALCITONIN-SALMON 200 UNITS SP

F4 117

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 118

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 119

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 120

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 121

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 122

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 123

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 124

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 125

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 126

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 127

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

DANTROLENE SODIUM 100 MG CAPDANTROLENE SODIUM 20 MG VIALDANTROLENE SODIUM 25 MG CAPDANTROLENE SODIUM 50 MG CAP

F4 128

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 129

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 130

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 131

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 132

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 133

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 134

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 135

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

ENBREL 50 MG/ML MINI CARTRIDGE

F4 136

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 137

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 138

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 139

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 140

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 141

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 142

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 143

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

FLUTICASONE-SALMETEROL 100-50FLUTICASONE-SALMETEROL 113-14FLUTICASONE-SALMETEROL 232-14FLUTICASONE-SALMETEROL 250-50FLUTICASONE-SALMETEROL 500-50FLUTICASONE-SALMETEROL 55-14

F4 144

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 145

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 146

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 147

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 148

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

HUMIRA PEDIATRIC CROHN'S START

HUMIRA PEN CROHN'S-UC-HS STARTHUMIRA PEN PSORIASIS-UVEITIS-AHUMIRA(CF) 10 MG/0.1 ML SYRINGHUMIRA(CF) 20 MG/0.2 ML SYRINGHUMIRA(CF) 40 MG/0.4 ML SYRINGHUMIRA(CF) PEDIATRIC CROHN'S S

F4 149

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

HUMIRA(CF) PEN CROHN'S-UC-HS SHUMIRA(CF) PEN PS-UV-ADOL HS S

F4 150

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 151

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 152

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

ISOSORBIDE MONONIT 10 MG TABISOSORBIDE MONONIT 20 MG TABISOSORBIDE MONONIT ER 120 MGISOSORBIDE MONONIT ER 30 MG TBISOSORBIDE MONONIT ER 60 MG TB

F4 153

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 154

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 155

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 156

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 157

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 158

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 159

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 160

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

LUPRON DEPOT 11.25 MG 3MO KIT

F4 161

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

LUPRON DEPOT 22.5 MG 3MO KIT

F4 162

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 163

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 164

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 165

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 166

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 167

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 168

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 169

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 170

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 171

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 172

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 173

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

OCTREOTIDE 1,000 MCG/5 ML VIAL

OCTREOTIDE 5,000 MCG/5 ML VIALOCTREOTIDE ACET 0.05 MG/ML VLOCTREOTIDE ACET 100 MCG/ML AMPOCTREOTIDE ACET 100 MCG/ML SYROCTREOTIDE ACET 100 MCG/ML VLOCTREOTIDE ACET 200 MCG/ML VLOCTREOTIDE ACET 50 MCG/ML AMPOCTREOTIDE ACET 50 MCG/ML SYROCTREOTIDE ACET 50 MCG/ML VIALOCTREOTIDE ACET 500 MCG/ML AMPOCTREOTIDE ACET 500 MCG/ML SYROCTREOTIDE ACET 500 MCG/ML VL

F4 174

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

ONDANSETRON 4 MG/5 ML SOLUTION

F4 175

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

OXYCODONE HCL ER 10 MG TABLETOXYCODONE HCL ER 15 MG TABLETOXYCODONE HCL ER 20 MG TABLETOXYCODONE HCL ER 30 MG TABLETOXYCODONE HCL ER 40 MG TABLETOXYCODONE HCL ER 60 MG TABLETOXYCODONE HCL ER 80 MG TABLET

F4 176

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

PANTOPRAZOLE SOD DR 20 MG TABPANTOPRAZOLE SOD DR 40 MG TABPANTOPRAZOLE SODIUM 40 MG VIAL

F4 177

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 178

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 179

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 180

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 181

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 182

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 183

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 184

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 185

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 186

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 187

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 188

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 189

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 190

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 191

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 192

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

STRIVERDI RESPIMAT INHAL SPRAY

F4 193

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

SYMBICORT 160-4.5 MCG INHALER

F4 194

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 195

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 196

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 197

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

TRAMADOL HCL ER 100 MG TABLETTRAMADOL HCL ER 200 MG TABLETTRAMADOL HCL ER 300 MG TABLET

F4 198

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 199

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

TUDORZA PRESSAIR 400 MCG INHTUDORZA PRESSAIR 400 MCG INHAL

F4 200

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 201

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 202

Appendix F4. Jai Medical Systems (Jai) Prescription Drugs Subject to NQTLs, by Delivery System

F4 203