Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO)

Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO) Step Therapy Requirements Effective 4/1/2019 Updated 3/2019

BRAND NAME ANTIDEPRESSANTS FETZIMA 120 MG CAPSULE,EXTENDED RELEASE FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK FETZIMA 20 MG CAPSULE,EXTENDED RELEASE FETZIMA 40 MG CAPSULE,EXTENDED RELEASE FETZIMA 80 MG CAPSULE,EXTENDED RELEASE PAXIL 10 MG/5 ML ORAL SUSPENSION TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG TABLET VIIBRYD 20 MG TABLET VIIBRYD 40 MG TABLET USE OF A FIRST LINE GENERIC ANTIDEPRESSANT IN SSRI/SNRI CLASS OR GENERIC BUPROPION HYDROCHLORIDE 1

BRAND NAME ATYPICAL ANTIPSYCHOTICS FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET LATUDA 120 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET REXULTI 0.25 MG TABLET REXULTI 0.5 MG TABLET REXULTI 1 MG TABLET REXULTI 2 MG TABLET REXULTI 3 MG TABLET REXULTI 4 MG TABLET SAPHRIS 10 MG SUBLINGUAL TABLET SAPHRIS 2.5 MG SUBLINGUAL TABLET SAPHRIS 5 MG SUBLINGUAL TABLET VRAYLAR 1.5 MG CAPSULE VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE PRIOR HISTORY OR USE OF ONE FIRST LINE GENERIC ATYPICAL ANTIPSYCHOTIC AGENT 2

BRAND NAME SEDATIVE HYPNOTICS BELSOMRA 10 MG TABLET BELSOMRA 15 MG TABLET BELSOMRA 20 MG TABLET BELSOMRA 5 MG TABLET ROZEREM 8 MG TABLET ZOLPIMIST 5 MG/SPRAY (0.1 ML) ORAL SPRAY USE OF A FIRST LINE GENERIC SEDATIVE HYPNOTIC AGENT 3

JUXTAPID JUXTAPID 10 MG CAPSULE JUXTAPID 20 MG CAPSULE JUXTAPID 30 MG CAPSULE JUXTAPID 40 MG CAPSULE JUXTAPID 5 MG CAPSULE JUXTAPID 60 MG CAPSULE FIRST LINE USE OF REPATHA 4

LEVETIRACETAM SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION SPRITAM 250 MG TABLET FOR ORAL SUSPENSION SPRITAM 500 MG TABLET FOR ORAL SUSPENSION SPRITAM 750 MG TABLET FOR ORAL SUSPENSION USE OF FIRST-LINE GENERIC LEVETIRACETAM 5

OPHTHALMIC BETA BLOCKERS betaxolol 0.5 % eye drops timolol maleate 0.25 % eye gel forming solution timolol maleate 0.5 % eye gel forming solution FIRST-LINE USE OF GENERIC TIMOLOL MALEATE 0.25% OR 0.5% EYE DROPS 6

ULORIC ULORIC 40 MG TABLET ULORIC 80 MG TABLET FIRST LINE USE OF ALLOPURINOL 7

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INDEX BELSOMRA 10 MG TABLET...3 BELSOMRA 15 MG TABLET...3 BELSOMRA 20 MG TABLET...3 BELSOMRA 5 MG TABLET... 3 betaxolol 0.5 % eye drops... 6 FANAPT 1 MG TABLET... 2 FANAPT 10 MG TABLET... 2 FANAPT 12 MG TABLET... 2 FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK... 2 FANAPT 2 MG TABLET... 2 FANAPT 4 MG TABLET... 2 FANAPT 6 MG TABLET... 2 FANAPT 8 MG TABLET... 2 FETZIMA 120 MG CAPSULE,EXTENDED RELEASE... 1 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK...1 FETZIMA 20 MG CAPSULE,EXTENDED RELEASE... 1 FETZIMA 40 MG CAPSULE,EXTENDED RELEASE... 1 FETZIMA 80 MG CAPSULE,EXTENDED RELEASE... 1 JUXTAPID 10 MG CAPSULE... 4 JUXTAPID 20 MG CAPSULE... 4 JUXTAPID 30 MG CAPSULE... 4 JUXTAPID 40 MG CAPSULE... 4 JUXTAPID 5 MG CAPSULE...4 JUXTAPID 60 MG CAPSULE... 4 LATUDA 120 MG TABLET...2 LATUDA 20 MG TABLET... 2 LATUDA 40 MG TABLET... 2 LATUDA 60 MG TABLET... 2 LATUDA 80 MG TABLET... 2 PAXIL 10 MG/5 ML ORAL SUSPENSION... 1 REXULTI 0.25 MG TABLET...2 REXULTI 0.5 MG TABLET...2 REXULTI 1 MG TABLET... 2 REXULTI 2 MG TABLET... 2 REXULTI 3 MG TABLET... 2 REXULTI 4 MG TABLET... 2 ROZEREM 8 MG TABLET... 3 SAPHRIS 10 MG SUBLINGUAL TABLET... 2 SAPHRIS 2.5 MG SUBLINGUAL TABLET... 2 SAPHRIS 5 MG SUBLINGUAL TABLET... 2 SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION... 5 SPRITAM 250 MG TABLET FOR ORAL SUSPENSION... 5 SPRITAM 500 MG TABLET FOR ORAL SUSPENSION... 5 SPRITAM 750 MG TABLET FOR ORAL SUSPENSION... 5 timolol maleate 0.25 % eye gel forming solution... 6 timolol maleate 0.5 % eye gel forming solution... 6 TRINTELLIX 10 MG TABLET... 1 TRINTELLIX 20 MG TABLET... 1 TRINTELLIX 5 MG TABLET... 1 ULORIC 40 MG TABLET...7 ULORIC 80 MG TABLET...7 VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK... 1 VIIBRYD 10 MG TABLET... 1 VIIBRYD 20 MG TABLET... 1 VIIBRYD 40 MG TABLET... 1 VRAYLAR 1.5 MG CAPSULE... 2 VRAYLAR 3 MG CAPSULE... 2 VRAYLAR 4.5 MG CAPSULE... 2 VRAYLAR 6 MG CAPSULE... 2 ZOLPIMIST 5 MG/SPRAY (0.1 ML) ORAL SPRAY...3 9