Updates on Existing Criteria
August 2024. The following changes to criteria are effective August 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Benralizumab – update age restriction
- Eculizumab – update appropriate treatment and exclusion criteria
- Endothelin Receptor Antagonists – update appropriate treatment and to add new drug (Opsynvi)
- Lovotibeglogene Autotemcel – update appropriate treatment regimen and coverage duration
- Ravulizumab-cwvz – update covered uses for new indication (neuromyelitis optica spectrum disorder), required medical information, and appropriate treatment
- Sotatercept-csrk – update appropriate treatment to include dose-rounding
- Targeted Immune Modulators – add Tofidence and Tyvenne to non-preferred medical drug list
- Tenofovir Alafenamide – update age restriction
Preferred Drug List (PDL) Changes
August 2024. The following changes to the drug list are effective August 22, 2024:
Formulary Additions
- Fasenra 10 mg/0.5 mL injection add Tier 3 with SP, quantity limit and prior authorization
- Hyrimoz (Sandoz) injection add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Opsynvi tablet add Tier 3 with SP, quantity limit and prior authorization
- Spevigo injection add Tier 3 with SP, limited access, quantity limit and medical necessity prior authorization
- Vardenafil tablet add Tier 1 with prior authorization
- Voydeya tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
Prior Authorization
- Remove
- Cinacalcet tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
August 2024. The following changes to the drug list are effective August 22, 2024:
Formulary Additions
- Fasenra 10 mg/0.5 mL injection add Tier 4 with SP, quantity limit and prior authorization
- Opsynvi tablet add Tier 4 with SP, quantity limit and prior authorization
- Voydeya tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
Prior Authorization
- Remove
- Cinacalcet tablet
Removed from Formulary
- Livalo tablet; consider pitavastatin, simvastatin, atorvastatin, lovastatin, rosuvastatin, fluvastatin, pravastatin
See the PacificSource Drug Lists page for the current drug list.