Step therapy — Select

Utilization management updates — January 1, 2022

Most medical conditions have many medication options. Although their clinical effectiveness may be the same, the costs can be very different. The step therapy program gives you the treatment you need, usually at a lower cost. This is a list of medications that have been added to the step therapy program. Here’s how it works: With this program, you must try a step 1 medication first, before a step 2 medication may be covered. When you bring a prescription to your pharmacy, our system will check the medication for step therapy requirements. If your pharmacy claims show you have tried a step 1 medication in the recent past, the step 2 medication may be filled. If not, the pharmacist will contact your doctor to explain next steps. If you see your medication listed, we encourage you to talk with your doctor about your treatment and medication options. If you have questions about the step therapy program, call the phone number on your member ID card.

Select Formulary 1 Step therapy — Select Step therapy medications The following medications have been added to a step therapy program. This means you must try a lower-cost medication (step 1) before a higher-cost medication (step 2) is covered.

Therapeutic use Step 1 medication Step 2 medication Anti-infectives HIV3 Any one of the following preferred brands: JULUCA, ATRIPLA SYMFI, SYMFI LO, TRIUMEQ OR CIMDUO and any one of the following preferred brands: ISENTRESS, TIVICAY CIMDUO TEMIXYS etravirine INTELENCE Oral brand Generic doxycycline or minocycline ACTICLATE, DORYX, DORYX MPC, tetracyclines DOXYCYCLINE HYCLATE DR, MINOLIRA, ORACEA, SOLODYN, TARGADOX, VIBRAMYCIN Both of the following generics: doxycycline AND SEYSARA minocycline Otic agents ofloxacin CETRAXAL, ciprofloxacin otic Both of the following generics: ofloxacin AND CIPRODEX ciprofloxacin-dexamethasone otic Topical Any one of the following generics: metronidazole CLEOCIN SUPP, CLEOCIN VAGINAL CREAM, antibiotics 0.75% vaginal gel, clindamycin 2% vaginal cream NUVESSA Cardiovascular Renin- Any one of the following generics: amlodipine- EDARBI, EDARBYCLOR, TEKTURNA HCT angiotensin benazepril, amlodipine-olmesartan, benazepril, system agents benazepril-HCTZ, candesartan, candesartan-HCTZ, captopril, captopril-HCTZ, enalapril, enalapril-HCTZ, fosinopril, fosinopril-HCTZ, irbesartan, irbesartan- HCTZ, lisinopril, lisinopril-HCTZ, losartan, losartan- HCTZ, moexipril, moexipril-HCTZ, olmesartan, olmesartan-HCTZ, olmesartan-amlodipine-HCTZ, perindopril, quinapril, quinapril-HCTZ, ramipril, telmisartan, telmisartan-HCTZ, trandolapril, trandolapril-verapamil Statins Any one of the following generics: atorvastatin, ALTOPREV, EZALLOR, FLOLIPID, LESCOL XL, fluvastatin, fluvastatin ER, lovastatin, pravastatin, LIPITOR, LIVALO, PRAVACHOL, SIMVASTATIN rosuvastatin, simvastatin SUSP, ZOCOR Any one of the following generics: atorvastatin, ZYPITAMAG fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin AND LIVALO1 Fibric acid Any one of the following generics: fenofibric FENOGLIDE, FIBRICOR, TRIGLIDE derivatives cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab AND LIPOFEN

Brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

2 Step therapy — Select

Therapeutic use Step 1 medication Step 2 medication Central nervous system ADHD agents Any two of the following generics or preferred ADDERALL2, ADHANSIA XR2, ADZENYS ER2, brands: amphetamine-dextroamphetamine IR, ADZENYS XR ODT2, APTENSIO XR2, CONCERTA2, dexmethylphenidate IR or ER, dextroamphetamine IR COTEMPLA XR-ODT2, DAYTRANA2, DESOXYN2, or SR, methylphenidate IR or ER DYANAVEL XR2, FOCALIN2, FOCALIN XR2, VYVANSE JORNAY PM2, KAPVAY, METADATE CD2, METHYLIN2 solution, MYDAYIS2, PROCENTRA2, QUILLICHEW ER2, QUILLIVANT2, RITALIN2, RITALIN LA2, ZENZEDI2 Any one of the following generics: atomexetine, QELBREE guanfacine, clonidine Anticonvulsants3 Any one of the following generics: lamotrigine IR, BRIVIACT, XCOPRI levetiracetam IR/ER, oxcarbazepine IR, topiramate IR topiramate IR QUDEXY XR, TROKENDI XR oxcarbazepine IR OXTELLAR XR Antidepressants3 bupropion ER APLENZIN2, FORFIVO XL2 Any two of the following generics: desvenlafaxine FETZIMA2 succinate ER, duloxetine, venlafaxine, venlafaxine ER Any two of the following generics: bupropion, DESVENLAFAXINE ER2, PAXIL suspension, citalopram, desvenlafaxine succinate ER, duloxetine, TRINTELLIX2 escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER Any one of the following generics: duloxetine DRIZALMA Antipsychotics3 Any two of the following generics: asenapine, CAPLYTA2, FANAPT2, SAPHRIS2, SECUADO2 aripiprazole, clozapine, olanzapine, paliperidone, quetiapine IR or ER, risperidone, ziprasidone Any one of the following generics: asenapine, VRAYLAR2 aripiprazole, clozapine, olanzapine, paliperidone, quetiapine IR or ER, risperidone, ziprasidone Insomnia agents Any one of the following generics: eszopiclone, BELSOMRA2, DAYVIGO2 temazepam, zaleplon, zolpidem, zolpidem CR Any one of the following generics: zolpidem, EDLUAR2, ZOLPIMIST2 zolpidem CR Migraine agents Any two of the following generics: almotriptan, ONZETRA XSAIL2, TOSYMRA2, TREXIMET2, eletriptan, frovatriptan, naratriptan, rizatriptan, ZOMIG NASAL2 sumatriptan, zolmitriptan Neurologic gabapentin GRALISE2 agents Any one of the following generics: amitriptyline, LYRICA CR2, SAVELLA2 cyclobenzaprine, duloxetine, gabapentin, pregabalin Non-narcotic Any two of the following generics: diclofenac, CAMBIA, DICLOFENAC capsules, INDOCIN analgesics diclofenac CR, diflunisal, etodolac, fenoprofen, suppository, INDOCIN suspension, flurbiprofen, ibuprofen, indomethacin, ketoprofen, INDOMETHACIN capsules, TIVORBEX, ketorolac, meclofenamate, meloxicam, nabumetone, VIVLODEX, ZORVOLEX naproxen, oxaprozin, piroxicam, sulindac, tolmetin Opioid NARCAN EVZIO antagonists naloxone injection LIFEMS Opioid clonidine LUCEMYRA2 withdrawal

Brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

3 Step therapy — Select

Therapeutic use Step 1 medication Step 2 medication Parkinson’s Any one of the following generics: pramipexole IR or NEUPRO disease ER, ropinirole IR or ER Any one of the following generics: carbidopa- RYTARY levodopa, carbidopa-levodopa CR Both of the following generics: rasagiline, selegiline XADAGO2 Any one of the following generics: entacapone ONGENTYS Dermatology Rosacea Any one of the following generics or preferred FINACEA GEL, NORITATE, ZILXI brands: azelaic acid gel, FINACEA FOAM, SOOLANTRA Any one of the following generics or preferred METROGEL brands: metronidazole gel, FINACEA FOAM, SOOLANTRA Skin cancer Any one of the following generics: fluorouracil, diclofenac gel 3%2, PICATO agents imiquimod 5% Both of the following generics: fluorouracil, KLISYRI imiquimod 5% imiquimod 5% imiquimod 3.75%, ZYCLARA Topical acne Any one of the following preferred brands: EPIDUO ACANYA, BENZACLIN, BENZAMYCIN, VELTIN, treatments FORTE, ONEXTON ZIANA Any two generic single-agent topical clindamycin CLINDAGEL products Topical immuno- tacrolimus ointment ELIDEL, pimecrolimus, PROTOPIC ointment modulators Any one of the following generics: alclometasone, EUCRISA amcinonide, betamethasone, calcipotriene- betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, pramoxine- HC, prednicarbate, triamcinolone, tacrolimus, pimecrolimus Endocrinology Basal insulin Any two of the following preferred brands: LANTUS, BASAGLAR, SEMGLEE LEVEMIR, TOUJEO, TRESIBA Diabetic agents Any one of the following generics: metformin, ACTOPLUS MET XR, AVANDIA, CYCLOSET, metformin ER, glipizide-metformin, glyburide- RIOMET, RIOMET ER metformin, pioglitazone-metformin Blood glucose CONTOUR NEXT, ONETOUCH ABBOTT2, ACCU-CHECK2, ACON2, meters and strips ADVOCATE2, AT LAST2, BAYER2, BIOTEL2, D-CARE2, DIATHRIVE2, EASYMAX2, EASYPLUS2, EMBRACE2, EPS2, EXACTECH2, FOR A CARE2, FORTISCARE2, FREESTYLE2, GENSTRIP2, GLUCOCARD2, GMATE2, INFINITY2, LIBERTY2, MICRODOT2, NEUTEK2, ON CALL2, OPTIUM2, PRECISION2, POGO2, QUINTET2, RELION2, REVEAL2, SUPREME2, TELCARE2, TRUE METRIX2, TRUETEST2, TRUETRACK2, ULTIMA2, UNISTRIP2, VERASENS2, VIVAGUARD2, VIVID PAL2 Glucagon Any one of the following preferred brands: GLUCAGEN HYPOKIT, ZEGALOGUE GLUCAGON, GVOKE, BAQSIMI

Brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

4 Step therapy — Select

Therapeutic use Step 1 medication Step 2 medication DPP4 inhibitors Any one of the following generics: metformin, JANUMET, JANUMET XR, JANUVIA, metformin ER, glipizide-metformin, glyburide- JENTADUETO, JENTADUETO XR, TRADJENTA metformin, pioglitazone-metformin Any one of the following preferred brands: ALOGLIPTIN, ALOGLIPTIN-METFORMIN, JANUMET1, JANUMET XR1, JANUVIA1 ALOGLIPTIN-PIOGLITAZONE, KAZANO, AND any one of the following preferred brands: KOMBIGLYZE XR, NESINA, ONGLYZA, OSENI JENTADUETO1, JENTADUETO XR1, TRADJENTA1 GLP-1 agonists Any one of the following generics: metformin, BYDUREON2, BYDUREON BCISE2, BYETTA2, metformin ER, glipizide-metformin, glyburide- OZEMPIC2, RYBELSUS2, TRULICITY2, VICTOZA2 metformin, pioglitazone-metformin Any one of the following preferred brands: ADLYXIN2 BYDUREON1, BYDUREON BCISE1, BYETTA1 AND any one of the following preferred brands: OZEMPIC1, RYBELSUS1, TRULICITY1, VICTOZA1 GLP-1 agonist Any one of the following generics: metformin, SOLIQUA2, XULTOPHY2 combinations metformin ER, glipizide-metformin, glyburide- metformin, pioglitazone-metformin SGLT2 inhibitors Any one of the following generics: metformin, FARXIGA metformin ER, glipizide-metformin, glyburide- metformin, pioglitazone-metformin OR any one of the following generics: captopril, enalapril, lisinopril, quinapril, ramipril, fosinopril, trandolapril, perindopril, candesartan, valsartan, losartan, bisoprolol, carvedilol IR, carvedilol ER, metoprolol succinate, spironolactone, eplerenone Any one of the following generics: metformin, GLYXAMBI, JARDIANCE, SYNJARDY, SYNJARDY metformin ER, glipizide-metformin, glyburide- XR, TRIJARDY XR, XIGDUO XR metformin, pioglitazone-metformin Any one of the following preferred brands: FARXIGA1, INVOKAMET, INVOKAMET XR, INVOKANA, XIGDUOR XR1 AND any one of the following QTERN, SEGLUROMET, STEGLATRO, STEGLUJAN preferred brands: GLYXAMBI1, JARDIANCE1, SYNJARDY1, SYNJARDY XR1, TRIJARDY XR1 Short-acting Any two of the following preferred brands: ADMELOG, APIDRA, FIASP, INSULIN ASPART, insulin HUMALOG, NOVOLOG, LYUMJEV INSULIN LISPRO, NOVOLOG RELION Gastroenterology Bowel prep Any one of the following brands: CLENPIQ, SUPREP OSMOPREP, MOVIPREP, PLENVU agents Constipation Any one of the following generics: lactulose, AMITIZA2 agents polyethylene glycol AND any one of the following preferred brands: LINZESS1, MOVANTIK1, SYMPROIC1 Any one of the following generics: lactulose, LINZESS2, MOVANTIK2, SYMPROIC2 polyethylene glycol Any one of the following generics: lactulose, RELISTOR2 polyethylene glycol AND any one of the following preferred brands: MOVANTIK1, SYMPROIC1 Any one of the following generics: lactulose, MOTEGRITY2, TRULANCE2 polyethylene glycol AND LINZESS1 Irritable bowel APRISO ASACOL HD, DELZICOL syndrome Pancreatic Both of the following preferred brands: CREON, PANCREAZE, PERTZYE, VIOKACE enzymes ZENPEP

Brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

5 Step therapy — Select

Therapeutic use Step 1 medication Step 2 medication Proton pump Any two of the following generics or preferred ACIPHEX2, ESOMEPRAZOLE STRONTIUM2, inhibitors brands: esomeprazole, omeprazole, lansoprazole, FIRST-LANSOPRAZOLE, FIRST-OMEPRAZOLE, pantoprazole, rabeprazole PREVACID2, PRILOSEC2, PROTONIX2, ZEGERID2 DEXILANT Hematology Coagulation NOVOSEVEN RT SEVENFACT factors3 Hormone modifiers Thyroid levothyroxine ARMOUR THYROID, LEVOTHYROXINE capsules, replacement NATURE-THROID, SYNTHROID, THYQUIDITY Vasopressin NOCDURNA NOCTIVA analogs Miscellaneous Antigout agents colchicine tablets COLCHICINE CAPS, COLCRYS, GLOPERBA, MITIGARE allopurinol ULORIC Intranasal Any one of the following generics or preferred XHANCE2 steroids brands: mometasone nasal spray or BECONASE AQ Clinical levetiracetam ER ELEPSIA XR duplicates Any two of the following generics: metoprolol KAPSPARGO tartrate, metoprolol succinate ER, bisoprolol, betaxolol, carvedilol IR or ER, labetalol, atenolol, acebutolol, propranolol IR or ER, pindolol, nadolol Obstetrics and gynecology Contraceptives Any two of the following generics: norethindrone SLYND 0.35 mg, Deblitane, Sharobel, Norlyda, Lyza, Tulana, Norlyroc, Errin, Nora-Be, Jolivette, Heather, Incassia, Jencycla, Camila Any one of the following generics: Gemmily, TAYTULLA Merzee, norethindrone-ethinyl estradiol-ferrous fumarate Generic oral formulation of levonorgestrel/ethinyl TWIRLA estradiol AND Xulane or Zafemy Hormone estradiol patch ALORA, MENOSTAR, MINIVELLE replacement Any one of the following preferred brands: FEMRING IMVEXXY, OSPHENA, PREMARIN VAGINAL CREAM Any two of the following preferred brands: INTRAROSA IMVEXXY, OSPHENA, PREMARIN VAGINAL CREAM Oncology Chemotherapy levoleucovorin KHAPZORY rescue agents Ophthalmology Antiglaucoma All of the following generics and preferred brands: VYZULTA2, XELPROS2 agents latanoprost, travoprost, LUMIGAN Ophthalmic Both of the following generics: BEPREVE, LASTACAFT, PAZEO, ZERVIATE antihistamines azelastine AND olopatadine

Brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

6 Step therapy — Select

Therapeutic use Step 1 medication Step 2 medication Ophthalmic Any one of the following generics: diclofenac soln, BROMSITE2, ILEVRO2, NEVANAC2 antiinflammatory flurbiprofen soln, ketorolac soln AND PROLENSA agents Respiratory Cystic fibrosis Both of the following generics: tobramycin 300mg/4 BETHKIS, KITABIS, TOBI (inhaled mL, tobramycin 300 mg/5 mL tobramycin agents) Epinephrine auto Generic epinephrine AUVI-Q 0.3 mg, AUVI-Q 0.15 mg, EPIPEN, injectors EPIPEN-JR Inhaled Any two of the following preferred brands: ALVESCO2, ARMONAIR2, ASMANEX2 corticosteroids ARNUITY ELLIPTA, FLOVENT, PULMICORT FLEXHALER, QVAR REDIHALER Leukotriene Any one of the following generics: montelukast, zileuton ER, ZYFLO, ZYFLO CR modifiers zafirlukast Long-acting Any two of the following preferred brands: ADVAIR, ARCAPTA bronchodilators BREO ELLIPTA, SEREVENT, STRIVERDI RESPIMAT, SYMBICORT SPIRIVA INCRUSE ELLIPTA2, SEEBRI NEOHALER2, TUDORZA PRESSAIR2, Long-acting Any two of the following preferred brands: ADVAIR, AIRDUO2, DULERA2 bronchodilator BREO ELLIPTA, SYMBICORT combinations Both of the following preferred brands: ANORO BEVESPI AEROSPHERE2, DUAKLIR PRESSAIR2, ELLIPTA, STIOLTO RESPIMAT UTIBRON NEOHALER2 Short-acting beta albuterol HFA (manufactured by Cipla, Civica, Par, albuterol HFA2 (manufactured by Prasco), agonist inhalers Perrigo, or Teva) levalbuterol HFA2, PROAIR DIGIHALER2, PROAIR HFA2, PROAIR RESPICLICK2, PROVENTIL HFA2, VENTOLIN HFA2, XOPENEX HFA2 Urology BPH Agents Any two of the following generics: CARDURA XL alfuzosin, doxazosin, silodosin, tamsulosin, terazosin Overactive Any two of the following generics or preferred GELNIQUE, GEMTESA, OXYTROL2 bladder agents brand: generic oxybutynin IR/ER, generic tolterodine IR/ER, generic trospium IR/ER, generic solifenacin, generic darifenacin ER, MYRBETRIQ Overactive Any one of the following generics: oxybutynin IR/ER VESICARE LS bladder agents or oxybutynin syrup

Brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

7 Step therapy — Select

Therapeutic use Step 1 medication Step 2 medication Generic first Generic equivalent ABILIFY, ALTACE, ARIMIDEX, ARTHROTEC, ATACAND, AVAPRO, AVODART, AZOPT, BARACLUDE, BRISDELLE, BYSTOLIC, CANASA, CARBATROL, CARDIZEM LA, CARNITOR, CATAPRES-TTS, CELEXA, CIALIS, CLARINEX, CLIMARA, CLOBEX, COLESTID, COREG, CORTEF, COSOPT, COZAAR, DELESTROGEN, DEPAKOTE, DYAZIDE, EPIDUO, ESTRACE, EXFORGE, FIORICET, FLOMAX, GENERESS FE, GLUCOPHAGE, GOLYTELY, HYZAAR, IMITREX, INDERAL LA, KENALOG, KEPPRA, KLONOPIN, K-TAB, LAMICTAL, LASIX, LOESTRIN, LOTREL, LYRICA, MAXALT, MICARDIS, MOBIC, NALFON, NATROBA, NEURONTIN, NIASPAN, NULYTELY, ORTHO MICRON, ORTHO-CYCLEN, ORTHO-NOVUM, PATADAY, PATANOL, PAXIL, PLAQUENIL, PLAVIX, PRED FORTE, PRINIVIL, PROMETRIUM, QUESTRAN, RANEXA, RELPAX, RENAGEL, RESTORIL, RISPERDAL, SAFYRAL, SEASONIQUE, SEROQUEL, SILVADENE, SKELAXIN, SOMA, STRATTERA, SUBOXONE, TAMIFLU, TEGRETOL, TENORMIN, TIKOSYN, TIMOPTIC, TIMOPTIC-XE, TIMOPTIC OCUDOSE, TOPAMAX, TRAVATAN Z, TRICOR, TRILEPTAL, UCERIS, VALTREX, VANADOM, VECTICAL, VESICARE, VIGAMOX, WELCHOL, XALATAN, YASMIN, ZANAFLEX, ZESTRIL, ZONEGRAN, ZOVIRAX, ZYPREXA

Step therapy requirements are effective as of January 1, 2022. The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage. 1 These agents are also subject to additional step requirements as indicated in table. 2 Quantity limits may also apply. Please refer to the Select quantity limits document. 3 Applies to new starts only

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