SelectHealth Advantage 2021 Step Therapy Criteria Step Therapy Group Drug Name Criteria ACNE ADAPAL/BEN P Previous trial on at least ONE: AZELEX Generic topical acne treatment TRETINOIN ACTONEL RISEDRON SOD Previous trial on: RISEDRONATE alendronate ADAPALENE ADAPALENE Previous use of non-micronized tretinoin TAZAROTENE ANTICONVULSANT APTIOM Previous trial on at least TWO of the following: SPRITAM carbamezapine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, XCOPRI levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide ANTIDEPRESSION APLENZIN Previous trial on at least TWO of the following: EMSAM bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, FETZIMA mirtazapine, paroxetine, sertraline, venlafaxine, desvenlafaxine PEXEVA TRINTELLIX VIIBRYD ANTIPSYCHOTIC ARISTADA Previous trial on at least ONE of the following: ASENAPINE aripiprazole, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, FANAPT quetiapine, risperidone, ziprasidone LATUDA PALIPERIDONE SECUADO VRAYLAR BELSOMRA BELSOMRA Previous trial on at least ONE of the following: zaleplon, zolpidem, eszopiclone BUDESONIDE BUDESONIDE TAB Previous trial of ONE of the following: Mesalamine, Pentasa CADUET AMLOD/ATORVA Previous trial on at least ONE of the following: atorvastatin, lovastatin, pravastatin, simvastatin AND Previous trial on: amlodipine

Updated 8/25/2021 1 SelectHealth Advantage 2021 Step Therapy Criteria Step Therapy Group Drug Name Criteria CAPEX CAPEX Previous trial on: clobetasol shampoo OR ciclopirox shampoo 1% CLOMIPRAMINE CLOMIPRAMINE Previous trial on at least ONE of the following: amitriptyline, amoxapine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, trimipramine CLONIDINE CLONIDINE TAB Previous trial on guanfacine er CORLANOR BYSTOLIC Previous trial on at least ONE of the following: CORLANOR acebutolol, atenolol, bisoprolol, labetolol, metoprolol, nadolol, pindolol, propranolol, timolol DAPSONE DAPSONE Previous use of topical clindamycin AND topical erythromycin DEMSER METYROSINE Previous trial on: phenoxybenzamine DERM PIMECROLIMUS Previous trial on: tacrolimus AND Previous trial on at least ONE of the following: betamethasone, clobetasol, hydrocortisone, triamcinolone DEXILANT DEXILANT Previous trial on at least ONE of the following: lansoprazole, omeprazole, pantoprazole DIABETES FARXIGA TAB Previous trial on metformin, metformin ER, glipizide/metformin, GLYXAMBI TAB glyburide/metformin, OR pioglitazone/metformin (Note: step therapy JARDIANCE TAB requirement can be bypassed by submitting a request if dapagliflozin is being JENTADUETO TAB used to reduce the risk of hospitalization for heart failure in adults with type 2 SOLIQUA INJ diabetes and CVD or multiple CV risk factors, if dapagliflozin is being used to SYNJARDY TAB reduce the risk of CVD death and hospitalization in adults with heart failure, or SYNJARDY XR TAB if empagliflozin is being used to reduce risk of cardiovascular events in adults TRADJENTA TAB with type 2 diabetes mellitus) TRIJARDY XR TAB XIGDUO XR TAB

Updated 8/25/2021 2 SelectHealth Advantage 2021 Step Therapy Criteria Step Therapy Group Drug Name Criteria EDARBYCLOR EDARBYCLOR Previous trial on at least ONE of the following: candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan, amlodipine/olmesartan, amlodipine/valsartan, candesartan/HCTZ, irbesartan/HCTZ, losartan/HCTZ, olmesartan/amlodipine/HCTZ, olmesartan/HCTZ, telmisartan/amlodipine, telmisartan/HCTZ, valsartan/HCTZ, amlodipine/valsartan/HCTZ EPLERENONE EPLERENONE Previous trial on at least ONE of the following: spironolactone, spironolactone-HCTZ EQUETRO EQUETRO CAP Previous trial on at least ONE of the following: carbamezapine er, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone EUCRISA EUCRISA OIN Previous trial of at least ONE of the following: 1. Topical Corticosteroid 2. Topical tacrolimus GASTRO MESALAMINE Previous trial on at least ONE of the following: balsalazide, mesalamine 375 mg, Pentasa, sulfasalazine GEMTESA GEMTESA Previous trial on: Myrbetriq KLARON SULFACETAMID Previous use of topical clindamycin OR topical erythromycin MOVIPREP PLENVU Previous trial on at TWO of the following: Suprep, Clenpiq NAMENDA MEMANTINE HC Previous trial on: NAMENDA XR immediate release Memantine NEUAC CLINDAM/BENZ Previous use of clindamycin-BPO 1.2%-5% CLINDAMY/BEN ERY/BENZOYL OAB GELNIQUE Previous trial on at least TWO of the following: oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er, solifenacin, darifenacin ONGENTYS ONGENTYS Previous use of two of: entacapone, tolcapone, amantadine, bromocriptine, Inbrija, Apokyn, Kynmobi, pramipexole, ropinirole, rasagiline, selegiline, Zelapar, Neupro

Updated 8/25/2021 3 SelectHealth Advantage 2021 Step Therapy Criteria Step Therapy Group Drug Name Criteria ORTIKOS ORTIKOS CAP 6MG ER Previous use of budesonide 3 mg caps ORTIKOS CAP 9MG ER PICATO PICATO GEL 0.015% Previous trial on at least ONE of the following: PICATO GEL 0.05% 1. Fluorouracil 5% 2. Imiquimod 5% PPI ESOMEPRA MAG Previous trial on at least TWO of the following: LANSOPRAZOLE lansoprazole, misoprostol, omeprazole, pantoprazole QELBREE QELBREE Previous trial of atomoxetine RANEXA RANOLAZINE Previous trial on at least ONE of the following: amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RAPAFLO SILODOSIN Previous trial of at least TWO of the following: alfuzosin, doxazosin, dutasteride, dutasteride/tamsulosin, finasteride, prazosin, tamsulosin, terazosin RASUVO RASUVO Previous trial on: REDITREX generic methotrexate RETIN TRETINOIN Previous use of non-micronized tretinoin AND adapalene SAVELLA SAVELLA Previous trial on at least ONE of the following: amitriptyline, desipramine, doxepin, imipramine, nortriptyline, protriptyline, trimipramine, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine SEGLUROMET SEGLUROMET Previous trial on ONE for the following: metformin, metformin ER, glipizide/metformin, glyburide/metformin, OR pioglitazone/metformin AND previous trial on ONE of the following: Synjardy OR Xigduo SLYND SLYND TAB Previous trial on: norethindrone 0.35 mg STATIN EZETIM/SIMVA TAB 10-10MG Previous trial on at least ONE of the following: EZETIM/SIMVA TAB 10-20MG atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin EZETIM/SIMVA TAB 10-40MG EZETIM/SIMVA TAB 10-80MG LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG

Updated 8/25/2021 4 SelectHealth Advantage 2021 Step Therapy Criteria Step Therapy Group Drug Name Criteria STEGLATRO STEGLATRO Previous trial on ONE for the following: metformin, metformin ER, glipizide/metformin, glyburide/metformin, OR pioglitazone/metformin AND previous trial on ONE of the following: Farxiga OR Jardiance STIMULANTS DAYTRANA Previous trial on at least ONE: VYVANSE generic long-acting stimulant OR Diagnosis of binge eating disorder SYMLIN SYMLINPEN 60 Previous trial on: SYMLNPEN 120 insulin TAZORAC TAZORAC Previous use of tazarotene TEKTURNA ALISKIREN Previous trial on at least ONE of the following: TEKTURNA HCT benazepril, benazepril-HCTZ, captopril, enalapril, enalapril-HCTZ, fosinopril, fosinopril-HCTZ, lisinopril, lisinopril-HCTZ, quinapril, quinapril-HCTZ, ramipril AND Previous trial on at least ONE of the following: candesartan, candesartan-HCTZ, irbesartan, irbesartan-HCTZ, losartan, losartan-HCTZ, olmesartan, olmesartan-HCTZ, telmisartan, telmisartan-HCTZ, valsartan, valsartan-HCTZ TIZANIDINE TIZANIDINE CAP 2MG Previous trial on: TIZANIDINE CAP 4MG tizanidine tablets TIZANIDINE CAP 6MG TOVIAZ TOVIAZ Previous trial on Myrbetriq TRIPTAN CAMBIA Previous trial on at least ONE of the following: FROVATRIPTAN sumatriptan OR rizatriptan SUMATRIPTAN ZOMIG TRULANCE MOTEGRITY Previous trial on Linzess TRULANCE VYZULTA RHOPRESSA Previous trial on: ROCKLATAN latanoprost VYZULTA ZELAPAR ZELAPAR Previous trial on: selegiline

Updated 8/25/2021 5 SelectHealth Advantage 2021 Step Therapy Criteria

Index Acne ...... 1 Ranexa...... 4 Actonel ...... 1 Rapaflo ...... 4 Adapalene ...... 1 Rasuvo...... 4 Anticonvulsant ...... 1 Retin...... 4 Antidepression ...... 1 Savella ...... 4 Antipsychotic...... 1 Segluromet...... 4 Belsomra ...... 1 Slynd...... 4 Budesonide ...... 1 Statin ...... 4 Caduet...... 1 Steglatro...... 5 Capex...... 2 Stimulants ...... 5 Clomipramine...... 2 Symlin...... 5 Clonidine ...... 2 Tazorac...... 5 Corlanor ...... 2 Tekturna...... 5 Dapsone ...... 2 Tizanidine ...... 5 Demser...... 2 Toviaz ...... 5 Derm ...... 2 Triptan...... 5 Dexilant ...... 2 Trulance ...... 5 Diabetes ...... 2 Vyzulta...... 5 Edarbyclor ...... 3 Zelapar ...... 5 Eplerenone...... 3 Equetro...... 3 Eucrisa...... 3 Gastro...... 3 Gemtesa ...... 3 Klaron...... 3 Moviprep...... 3 Namenda...... 3 Neuac ...... 3 Oab...... 3 Ongentys ...... 3 Ortikos...... 4 Picato ...... 4 Ppi ...... 4 Qelbree ...... 4

Updated 8/25/2021 6