Updates on Existing Criteria
August 2023. The following changes to criteria are effective August 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Abilify Maintena (rename Aripiprazole Long Acting Intramuscular Injections) – update covered uses and include Abilify Asimtufii
- Addyi & Vyleesi – update covered uses and exclusion criteria
- Avatrombopag – update required medical information and covered uses
- Coagadex – update covered uses and exclusion criteria
- Defibrotide – update covered uses, duration and required medical information
- Eculizumab – update covered uses, appropriate treatment regimen and required medical information
- Efgartigimod Alpha – update covered uses, clarify appropriate treatment regimen and coverage duration
- Elaprase – list covered use and update required medical information
- Eltrombopag – update covered uses and clarified coverage for chronic immune thrombocytopenia (ITP)
- Enspryng (rename Satralizumab-mwge) – update required medical information and appropriate treatment regimen
- Fostamatinib - update required medical information and covered uses
- Laronidase – list covered uses and update baseline value testing and reauthorization criteria
- Myeloid Growth Factors – update appropriate treatment regimen and criteria for prophylaxis of febrile neutropenia
- Niraparib – update appropriate treatment
- Oncology Agents – update to include Zynyz and Yervoy
- Oxybates – update to include Lumryz
- Pegcetacoplan – update required medical information and reauthorization criteria
- Ravulizumab – list covered uses and update required medical information
- Rebyota (rename Fecal Microbiota) – update to include coverage for Vowst
- Trikafta – update age restriction
- Uplizna (rename Inebilizumab-cdon) – update required medical information
- Vigabatrin – update required medical information and covered uses/duration
- Vistogard – update covered uses, duration and appropriate treatment regimen
- VMAT2 Inhibitors – update to include Austedo XR
- Xgeva – update appropriate treatment regimen
- Yervoy – remove stand-alone policy and add to Oncology Agents
Preferred Drug List (PDL) Changes
August 2023. The following changes to the drug list are effective August 22, 2023:
Formulary Additions
- Abilify Asimtufii prefilled syringe add Tier 3 with prior authorization
- Austedo titration pack add Tier 3 with SP and prior authorization
- Austedo XR tablet add Tier 3 with SP, quantity limit and prior authorization
- Baclofen oral suspension add Tier 1 with quantity limit and medical necessity prior authorization
- Daybue solution add Tier 3 with SP, quantity limit and prior authorization
- Dichlorphenamide tablet add Tier 1 with prior authorization
- Erleada tablet add Tier 3 with SP and prior authorization
- Gefitinib tablet add Tier 1 with SP, quantity limit and prior authorization
- Lenalidomide capsule add Tier 1 with SP and prior authorization
- Lumakras tablet add Tier 3 with SP and prior authorization
- Lumryz packet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Methsuximide capsule add Tier 1
- Miglustat capsule add Tier 3 with SP, limited access and prior authorization
- Moderna COVID-19 vaccine add Tier 0 (ACA vaccine)
- Naftifine gel add Tier 1
- Neulasta solution add Tier 3 with SP and prior authorization
- Orenitram pack add Tier 3 with SP, quantity limit and prior authorization
- Paroxetine capsule add Tier 1 with quantity limit
- Pirfenidone capsule add Tier 1 with SP, quantity limit and prior authorization
- Remodulin solution add Tier 1 with SP and prior authorization
- Skyrizi cartridge add Tier 3 with SP, quantity limit and prior authorization
- Treprostinil solution add Tier 1 with SP and prior authorization
- Trikafta pack add Tier 3 with SP, limited access, quantity limit and prior authorization
- Valrubicin solution add Tier 1
- Vowst capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
Quantity Limit
- Add Quantity Limit
- Memantine extended-release capsule
- Metformin modified release 1000mg tablet
- Paroxetine capsule
- Update Quantity Limit
- Orencia prefilled syringe
- Rapaflo capsule
- Silodosin capsule
Prior Authorization
- Add medical necessity
- Noxafil packet
- Noxafil suspension
- Noxafil tablet
- Remove prior authorization
- Ivermectin tablet
- Memantine extended-release capsule
- Stromectol tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
August 2023. The following changes to the drug list are effective August 22, 2023:
Formulary Additions
- Austedo titration pack add Tier 4 with SP and prior authorization
- Austedo XR tablet add Tier 4 with SP, quantity limit and prior authorization
- Daybue solution add Tier 4 with SP, quantity limit and prior authorization
- Erleada tablet add Tier 4 with SP and prior authorization
- Fentanyl patch add Tier 1 with step therapy and prior authorization (may apply)
- Gamifant solution add Tier 4 with SP and prior authorization
- Gefitinib tablet add Tier 4 with SP, quantity limit and prior authorization
- Lenalidomide capsule add Tier 4 with SP and prior authorization
- Lumakras tablet add Tier 4 with SP and prior authorization
- Lumryz packet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Mayzent tablet add Tier 3 with SP, quantity limit and prior authorization
- Memantine extended-release capsule add Tier 1 with quantity limit
- Metformin modified release tablet add Tier 1 with quantity limit
- Methsuximide capsule add Tier 1
- Miglustat capsule add Tier 4 with SP and prior authorization
- Moderna COVID-19 vaccine add Tier 0 (ACA vaccine)
- Naftifine gel add Tier 1
- Paroxetine capsule add Tier 1 with quantity limit
- Pirfenidone capsule add Tier 4 with SP, quantity limit and prior authorization
- Rebinyn solution add Tier 4 with SP and prior authorization
- Skyrizi cartridge add Tier 4 with SP, quantity limit and prior authorization
- Tobramycin nebulizer solution add Tier 4 with SP, quantity limit and prior authorization
- Trikafta packet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Vowst capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
Prior Authorization Removal
- Ivermectin tablet
Quantity Limit Update
- Silodosin capsule
Removed from Formulary
- Celontin capsule; consider methsuximide capsule
- Cystadane powder; consider betaine powder
- Iressa tablet; consider gefitinib tablet
- Ivermectin lotion; consider permethrin cream, malathion lotion
- Naftin gel; consider naftifine gel
- Zavesca capsule; consider miglustat capsule
See the PacificSource Drug Lists page for the current drug list.