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December 2020 Drug List Change Notification

Updates on Existing Criteria:

December 2020. The following changes to criteria are effective December 22, 2020:

Preauthorization Criteria – Clinical Updates

  • Cannabidiol – update to include new indication of Tuberous Sclerosis Complex (TSC)
  • Ecallantide – update required medical information and laboratory values
  • Givosiran – update diagnostic criteria for acute hepatic porphyria
  • Niraparib – update appropriate treatment regimen for each category
  • Nusinersen – update to require treatment failure with Evrysdi
  • Soliris - update required medical information for diagnosis of neuromyelitis Optica Spectrum Disorder
  • Spravato – update to include new indication of major depressive disorder with acute suicidal ideation or behavior
  • Targeted Immune Modulators – update to include new indication for Tremfya (Psoriatic Arthritis)
  • Tecentriq – remove stand-alone policy and add to General Oncology Agent criteria
  • Triptan step therapy – rename Migraine Agents and update to require single step one drug
  • Uplizna – update required medical information for diagnosis of neuromyelitis Optica Spectrum Disorder
  • Vectibix – remove stand-alone policy and add to General Oncology Agent criteria
  • Xeomin, Dysport and Myobloc – update age limit for Xeomin

Preauthorization Criteria – Clerical Updates

  • Synagis – rename Palivizumab
  • Ventavis – rename Iloprost
  • Zinplava – rename Bezlotoxumab

Preferred Drug List (PDL) Changes

December 2020. The following changes to the drug list are effective December 22, 2020:

Formulary Additions

  • AirDuo digihaler add Tier 3 with quantity limit and medical necessity preauthorization
  • Akynzeo injectable solution add Tier 3 with preauthorization
  • Albuterol HFA inhaler add Tier 1 with quantity limit
  • ArmonAir digihaler add Tier 3 with quantity limit and medical necessity preauthorization
  • Butalbital-acetaminophen tablet add Tier 1 with quantity limit and medical necessity preauthorization
  • Chlordiazepoxide-clidinium bromide capsule add Tier 1 with medical necessity preauthorization
  • Ciprofloxacin-dexamethason OTIC susp 0.3-0.1% add Tier 1
  • Cystadrops solution add Tier 3 with SP, limited access and preauthorization
  • Deferasirox packet add Tier 3 with SP and medical necessity preauthorization
  • Deferasirox tablet add Tier 1 with SP and preauthorization
  • Desonide 0.05% gel add Tier 1 with medical necessity preauthorization
  • Diclotrex pack add Tier 3 with medical necessity preauthorization
  • Dimethyl fumerate starter pack add Tier 3 with SP, quantity limit and preauthorization
  • Doxycycline hyclate tablet add Tier 1
  • Egrifta SV solution add Tier 3 medical necessity preauthorization
  • Emtricitabine-Tenofovir 200-300mg tablet add Tier 1 with quantity limit
  • Enbrel 25mg/0.5ml solution add Tier 3 with SP, quantity limit and preauthorization
  • Enspryng solution add Tier 3 with SP, quantity limit and preauthorization
  • Evrysdi oral solution add Tier 3 with quantity limit and preauthorization
  • Gavreto capsule add Tier 3 with SP, quantity limit and preauthorization
  • Gimoti nasal solution add Tier 3 with medical necessity preauthorization
  • Halog solution 0.1% add Tier 3 with medical necessity preauthorization
  • Hemady tablet add Tier 3 with medical necessity preauthorization
  • Jynarque therapy pack add Tier 3 with SP, limited access and preauthorization
  • Kesimpta auto-injector add Tier 3 with medical necessity preauthorization
  • Ketorolac nasal spray add Tier 1 with medical necessity preauthorization
  • Lamotrigine kit add Tier 1
  • Lapatinib ditosylate tablet add Tier 1 with SP, quantity limit and preauthorization
  • Librax capsule add Tier 3 with medical necessity preauthorization
  • Methylphenidate extended release 24 hour (XR) capsule add Tier 1 with quantity limit and preauthorization for ages 6-12 years (new starts only)
  • Micafungin injectable solution add Tier 1
  • Naproxen-esomeprazole DR tablet add Tier 1 with medical necessity preauthorization
  • Nitisinone capsule add Tier 1 with medical necessity preauthorization
  • Nymalize solution add Tier 3
  • Ongentys capsule add Tier 3 with quantity limit
  • Onureg tablet add Tier 3 with SP, quantity limit and preauthorization
  • Pantoprazole packet add Tier 1 with quantity limit
  • ProAir Digihaler add Tier 3 with quantity limit and medical necessity preauthorization
  • Relafen DS tablet add Tier 3 with medical necessity preauthorization
  • Relafen tablet add Tier 3 with medical necessity preauthorization
  • Sapropterin dihydrochloride soluble tablet and packet add Tier 1 with SP and preauthorization
  • Semglee solution add Tier 3 with medical necessity preauthorization
  • Subvenite starter kit add Tier 1
  • Targadox tablet add Tier 3 with medical necessity preauthorization
  • Tiadylt ER capsule add Tier 1
  • Tolvaptan tablet add Tier 1 with SP, quantity limit and preauthorization
  • Trulicity Pen injector add Tier 2 with quantity limit and step therapy
  • Upneeq solution add Tier 3 with quantity limit
  • Vanatol S solution add Tier 1 with quantity limit and medical necessity preauthorization
  • Varubi therapy pack add Tier 3 with quantity limit and preauthorization
  • Vtol LQ solution add Tier 1 with quantity limit and medical necessity preauthorization
  • Ziprasidone mesylate injectable solution add Tier 1

Quantity Limit Update

  • Remove quantity limit
    • Nubeqa tablet
  • Add quantity limit
    • Corlanor tablet and solution
    • Mydayis capsule
    • Xigduo XR
  • Update quantity limit
    • Imitrex solution
    • Imitrex STATdose system
    • Maxalt tablet
    • Rizatriptan tablet
    • Tosymra solution
    • Vanatol LQ solution
    • Zolmitriptan tablet
    • Zomig tablet and nasal solution
    • Zomig ZMT tablet

Preauthorization Update

  • Remove preauthorization
    • Ubrelvy tablet
  • Add preauthorization
    • Akynzeo capsule
    • Cystaran solution
  • Add medical necessity preauthorization
    • Asmanex HFA inhaler
    • Asmanex inhaler
    • Ciprodex OTIC suspension

Tier Update

  • Asmanex HFA inhaler
  • Asmanex inhaler
  • Ciprodex OTIC suspension
  • Kuvan tablet and packet
  • Mydayis capsule
  • Oxytrol patch
  • ProAir HFA
  • ProAir Respiclick
  • Ubrelvy tablet
  • Vanatol LQ solution
  • Vyvanse capsule and chewable tablet

Step Therapy Update

  • Add step therapy
    • Ubrelvy tablet
  • Remove step therapy
    • Eucrisa Ointment
    • Pimecrolimus ointment
    • Protopic ointment
    • Tacrolimus ointment

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes

December 2020. The following changes to the drug list are effective December 22, 2020:

Formulary Additions

  • Albuterol HFA inhaler add Tier 1 with quantity limit
  • Aminocaproic acid tablet add Tier 1
  • Ciprofloxacin-dexamethason OTIC susp 0.3-0.1% add Tier 1
  • Cystadrops solution add Tier 4 with SP and preauthorization
  • Doxylamine-pyridoxine DR tablet add Tier 1
  • Efavirenz-emtricitabine-tenofovir DF tablet add Tier 1
  • Emtricitabine-Tenofovir 200-300mg tablet add Tier 1 with quantity limit
  • Enbrel 25mg/0.5ml solution add Tier 4 with SP, quantity limit and preauthorization
  • Enspryng solution add Tier 4 with SP and preauthorization
  • Gavreto capsule add Tier 4 with SP, quantity limit and preauthorization
  • Jynarque therapy pack add Tier 4 with SP, limited access, quantity limit and preauthorization
  • Lapatinib ditosylate tablet add Tier 4 with SP, quantity limit and preauthorization
  • Micafungin injectable solution add Tier 1
  • Mydayis capsule add Tier 2 with quantity limit and preauthorization for ages 6-12 years (new start only)
  • Nitisinone capsule add Tier 4 with SP and preauthorization
  • Ongentys capsule add Tier 3 with quantity limit
  • Onureg tablet add Tier 4 with SP, quantity limit and preauthorization
  • Sapropterin dihydrochloride tablet and packet add Tier 4 with SP and preauthorization
  • Semglee solution add Tier 3 with medical necessity preauthorization
  • Sildenafil citrate oral suspension add Tier 4 with SP and preauthorization
  • Tolvaptan tablet add Tier 4 with SP, limited access, quantity limit and preauthorization
  • Trulicity Pen injector add Tier 2 with quantity limit and step therapy
  • Ubrelvy tablet add Tier 2 with quantity limit and step therapy
  • Upneeq solution add Tier 3 with quantity limit
  • Ziprasidone mesylate injectable solution add Tier 1

Step Therapy Update

  • Remove step therapy
    • Eucrisa Ointment
    • Pimecrolimus ointment
    • Tacrolimus ointment

Tier Update

  • Lumigan solution
  • Vyvanse capsule and chewable tablet
  • Zenpep capsule

Preauthorization Update

  • Add preauthorization
    • Akynzeo capsule
    • Cystaran solution

Quantity Limit Update

  • Remove quantity limit
    • Nubeqa tablet
  • Add quantity limit
    • Corlanor tablet and solution
    • Mydayis capsule
    • Xigduo XR
  • Update quantity limit
    • Rizatriptan tablet
    • Sumatriptan tablet and nasal solution
    • Zolmitriptan tablet
    • Zomig nasal solution

Removed from Formulary

  • Asmanex HFA inhaler; consider Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Qvar Redihaler
  • Asmanex inhaler; consider Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Qvar Redihaler
  • Cipro HC suspension; consider ciprofloxacin-dexamethasone OTIC susp 0.3-0.1%
  • Ciprodex suspension; consider ciprofloxacin-dexamethasone OTIC susp 0.3-0.1%
  • Geodon solution; consider ziprasidone mesylate solution
  • Kuvan; consider sapropterin dihydrochloride
  • Mycamine solution; consider micafungin solution
  • Orfadin capsule; consider nitisinone capsule
  • ProAir HFA and ProAir Respiclick; consider albuterol sulfate HFA, levalbuterol aerosol inhaler
  • Samsca tablet; consider tolvaptan tablet
  • Tykerb tablet; consider lapatinib ditosylate tablet

See the PacificSource Drug Lists page for the current drug list.