2021 Step Therapy Criteria EGWP Formulary ID: 21470

Drug Name Step Therapy Criteria APLENZIN (bupropion hbr) Must have a paid claims history of one of the following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate BAXDELA TABS ORAL 450 Must have a paid claims history of an alternative MG (delafloxacin meglumine) Fluoroquinolone with a look-back period of 30 days BUPROPION HCL ER (XL) Must have a paid claims history of one of the 450 MG TB24 (bupropion hcl) following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate DESVENLAFAXINE ER Must have a paid claims history of one of the (desvenlafaxine SR) following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate DEXILANT (dexlansoprazole) Must have a paid claims history of one of the following: • lansoprazole • omeprazole • pantoprazole esomeprazole magnesium Must have a paid claims history of two of the capsule following: • lansoprazole • omeprazole • pantoprazole FETZIMA (levomilnacipran Must have a paid claims history of one of the hcl) following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate

No changes made since 03/2021 EGWP_STC_2021 Drug Name Step Therapy Criteria FORFIVO XL (bupropion hcl) Must have a paid claims history of one of the following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate icosapent ethyl 1 gm cap Must have a paid claims history of: • omega-3-acid ethyl esters LOKELMA (sodium zirconium Must have a paid claims history of: cyclosilicate) • sodium polystyrene sulfonate powder omeprazole 20mg-sodium Must have a paid claims history of two of the bicarbonate 1680mg powd following: pack for susp • lansoprazole • omeprazole • pantoprazole PEXEVA (paroxetine Must have a paid claims history of one of the mesylate) following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate TRINTELLIX (vortioxetine Must have a paid claims history of one of the hbr) following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate VASCEPA 0.5 GM (icosapent Must have a paid claims history of: ethyl) • omega-3-acid ethyl esters VELTASSA (patiromer Must have a paid claims history of: sorbitex calcium) • sodium polystyrene sulfonate powder VEMLIDY (tenofovir Must have a paid claims history of: alafenamide fumarate) • entecavir, tenofovir disoproxil fumarate 300mg, or Baraclude oral solution venlafaxine hcl 225 mg ER Must have a paid claims history of one of the tab following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate Drug Name Step Therapy Criteria VIIBRYD (vilazodone hcl) Must have a paid claims history of one of the following: • mirtazapine, nefazodone, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, venlafaxine, bupropion, Paxil oral suspension, or desvenlafaxine succinate