Updates on Existing Criteria
August 2022. The following changes to criteria are effective August 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Axicabtagene Ciloleucel – update to include new indication as second line therapy for Large B-cell Lymphoma (LBCL)
- Betaseron – update required medical information and age restriction
- Galafold – Update confirmation of Fabry disease requirements
- Hepatitis C Direct Acting Antivirals – remove fibrosis staging and drug/alcohol screening, update appropriate treatment regimens
- Impavido – rename Miltefosine, remove age limit and lab monitoring
- Iobenguane I-131 – update required medical information and coverage duration
- Targeted Immune Modulators – add Rinvoq as preferred product for new indication (Ankylosing Spondylitis)
Preferred Drug List (PDL) Changes
August 2022. The following changes to the drug list are effective August 22, 2022:
Formulary Additions
- Adlarity patch add Tier 3 with quantity limit and medical necessity prior authorization
- Apomorphine solution add Tier 1 with SP and prior authorization
- Baclofen oral solution add Tier 1
- Camzyos capsule add Tier 3 with SP, quantity limit and prior authorization
- Crotan lotion add Tier 1
- Deferiprone talet add Tier 1 with SP, limited access and prior authorization
- Fiasp solution add Tier 2
- Glycopyrrolate tablet add Tier 3 with medical necessity prior authorization
- Gvoke kit add Tier 2 with quantity over time limit
- Igalmi film add Tier 3 with quantity over time limit and medical necessity prior authorization
- Indomethacin capsule add Tier 1 with medical necessity prior authorization
- Lacosamide oral solution add Tier 1
- Lagevrio capsule add Tier 0 with quantity over time limit (ACA limitations apply)
- Levamlodipine tablet add Tier 1 with medical necessity prior authorization
- Loreev XR capsule add Tier 3 with quantity limit and medical necessity prior authorization
- Nicacin (antihyperlipidemic) tablet add Tier 1
- Norliqva oral solution add Tier 3 with quantity limit and medical necessity prior authorization
- Quadracel vaccine add Tier 0 (ACA limitations apply)
- Qutenza patch kit add Tier 3 with medical necessity prior authorization
- Takhzyro prefilled syringe add Tier 3 with SP and prior authorization
- Valsartan oral solution add Tier 3 with medical necessity prior authorization
- Varenicline pack add Tier 0 (ACA limitations apply)
- Vilazodone tablet add Tier 1 with quantity limit and step therapy
Prior Authorization Update
- Add Prior Authorization
- Glycate tablet (Medical Necessity)
- Upneeq solution
Quantity Limit Updates
- Adderall tablet
- Amphetamine-dextroamphetamine tablet
- Aricept tablet
- Armodafinil tablet
- Donepezil tablet
- Nuvigil tablet
- Qelbree capsule
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
August 2022. The following changes to the drug list are effective August 22, 2022:
Formulary Additions
- Apomorphine solution add Tier 4 with SP and prior authorization
- Camzyos capsule add Tier 4 with SP, quantity limit and prior authorization
- Crotan lotion add Tier 1
- Deferiprone talet add Tier 4 with SP, limited access and prior authorization
- Fiasp solution add Tier 2
- Lacosamide oral solution add Tier 1
- Lagevrio capsule add Tier 0 with quantity over time limit (ACA limitations apply)
- Quadracel vaccine add Tier 0 (ACA limitations apply)
- Takhzyro prefilled syringe add Tier 4 with SP and prior authorization
- Varenicline pack add Tier 0 (ACA limitations apply)
- Vilazodone tablet add Tier 1 with quantity limit and step therapy
Prior Authorization Update
- Add Prior Authorization
- o Upneeq solution
Quantity Limit Updates
- Amphetamine-dextroamphetamine tablet
- Armodafinil tablet
- Donepezil tablet
Removed from Formulary
- Apokyn solution; consider apomorphine solution
- Eurax lotion; consider crotan lotion
- Ferriprox tablet; consider deferiprone tablet
- Revlimid capsule; consider lenalidomide capsule
- Vimpat tablet and solution; consider lacosamide tablet and solution
See the PacificSource Drug Lists page for the current drug list.