Updates on Existing Criteria
April 2025. The following changes to criteria are effective April 22, 2025:
Prior Authorization Criteria – Clinical Updates
- Addyi & Vyleesi – update with new policy
- Adzynma – update required medical information and appropriate treatment
- Botox – update coverage duration
- Calcitonin Gene-Related Peptide (CGRP) Inhibitors – remove Ajovy injection and Qulipta tablet from affected medications and update appropriate treatment
- Cannabidiol – update required medical information and appropriate treatment
- CFTR Modulators – update covered uses and age restriction
- Cialis – update required medical information, appropriate treatment, and prescriber restrictions
- Continuous Glucose Monitors – update required medical information
- Corlanor – update covered uses, required medical information, appropriate treatment, and exclusion criteria
- Emapalumab – update covered uses, required medical information, and appropriate treatment
- Emsam – update covered uses, appropriate treatment, and prescriber restrictions
- Erectile Dysfunction – update required medical information
- Evkeeza and Juxtapid – update required medical information, appropriate treatment, and age restriction
- Evolocumab – update required medical information, appropriate treatment, exclusion criteria, and prescriber restrictions
- Fecal Microbiota – update appropriate treatment
- GABA-A Receptor Modulators - update required medical information
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – update coverage duration
- Hepatitis C Direct-Acting Antivirals – update appropriate treatment and prescriber restrictions
- Inclisiran – update required medical information, appropriate treatment, exclusion criteria, and prescriber restrictions
- Mitapivat – update covered uses, required medical information, appropriate treatment, and exclusion criteria
- Myeloid Growth Factors – update covered uses and appropriate treatment
- Nemolizumab-ilto – update required medical information, appropriate treatment, and age restriction
- Non-Preferred Medical Drug Codes – update appropriate treatment
- Oncology Agents – add new drugs Bizengri, Revuforj, Aucatzyl, Opdivo Qvantig, and Danziten
- Oxervate – update required medical information and appropriate treatment
- Palovarotene – update covered uses, required medical information, and prescriber restrictions
- Tafamidis – update appropriate treatment, exclusion criteria, and policy name to “TTR Stabilizers”
- Targeted Immune Modulators – update non-preferred medical drugs
- Tenapanor – update required medical information and appropriate treatment
- Topical Dermatitis and Psoriatic Agents – update covered uses, appropriate treatment, and age restriction
- Trastuzumab – update appropriate treatment
- Ublituximab-xiiy – update appropriate treatment and exclusion criteria
- Verteporfin – update with new policy
Preferred Drug List (PDL) Changes
April 2025. The following changes to the drug list are effective April 22, 2025:
Formulary Additions
- Alyftrek tablet add tier 3 with SP, quantity limit, and prior authorization
- Attruby tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
- Bimzelx injection 320 mg/2 mL add tier 3 with SP and medical necessity prior authorization
- Crenessity capsule and solution add tier 3 with SP, limited access, quantity limit, and prior authorization
- Danziten tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
- Emrosi capsule add tier 3 with quantity limit and medical necessity prior authorization
- Imkeldi solution add tier 3 with SP, quantity limit, and medical necessity prior authorization
- Nypozi injection add tier 3 with SP, quantity limit, and prior authorization
- Opipza film add tier 3 with quantity limit and medical necessity prior authorization
- Revuforj tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
- Steqeyma injection add tier 3 with SP and medical necessity prior authorization
- Tryngolza injection add tier 3 with SP, limited access, quantity limit, and prior authorization
- Vyalev injection add tier 3 with SP, quantity limit, and prior authorization
- Wezlana injection add tier 3 with SP, limited access, and medical necessity prior authorization
- Zepbound injection add tier 3 with quantity limit and prior authorization
Prior Authorization
- Add Medical Necessity
- Ajovy injection
- Allopurinol 200 mg tablet
- Bimzelx injection
- Emrosi capsule
- Imkeldi solution
- Opipza film
- Qulipta tablet
- Steqeyma injection
- Wezlana injection
Removed from Formulary
- Braftovi 50 mg capsule
Quantity Limit
- Update
- Esbriet capsule and tablet
- Invokana tablet
Tier Update
- Allopurinol 200 mg tablet
- Hydromorphone liquid
- PEG-3350 reconstituted solution
Trimethoprim tablet
Removed from Limited Access
- Trikafta tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
April 2025. The following changes to the drug list are effective April 22, 2025:
Formulary Additions
- Alyftrek tablet add tier 4 with SP, quantity limit, and prior authorization
- Attruby tablet add tier 4 with SP, limited access, quantity limit, and prior authorization
- Crenessity capsule and solution add tier 4 with SP, limited access, quantity limit, and prior authorization
- Danziten tablet add tier 4 with SP, limited access, quantity limit, and prior authorization
- Revuforj tablet add tier 4 with SP, limited access, quantity limit, and prior authorization
- Tryngolza injection add tier 4 with SP, limited access, quantity limit, and prior authorization
- Vyalev injection add tier 4 with SP, quantity limit, and prior authorization
- Zepbound injection add tier 3 with quantity limit and prior authorization
Removed from Formulary
- Ajovy injection; consider Emgality, candesartan tablet, propranolol tablet, metoprolol tablet, timolol tablet, nadolol tablet, amitriptyline tablet, nortriptyline capsule, venlafaxine tablet capsule, duloxetine capsule, topiramate tablet
- Qulipta injection; consider Emgality, candesartan tablet, propranolol tablet, metoprolol tablet, timolol tablet, nadolol tablet, amitriptyline tablet, nortriptyline capsule, venlafaxine tablet capsule, duloxetine capsule, topiramate tablet
Removed from Limited Access
- Trikafta tablet
See the PacificSource Drug Lists page for the current drug list.