Updates on Existing Criteria:
December 2021. The following changes to criteria are effective December 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Anti-Cataplectics – rename Oxybates and update to include new Xywav indication of idiopathic hypersomnia
- Antidiabetic step therapy – add Jardiance and Farxiga exception bullet to allow for heart failure and kidney disease
- Belimumab – update prescriber restrictions
- Doptelet – rename Avatrombopag and update reauthorization criteria
- Parathyroid Hormone Analogs – Update appropriate treatment regimen and other criteria section
- Promacta – rename Eltrombopag and update required medical information with reauthorization criteria
Prior Authorization Criteria – Clerical Updates
- Signifor – define abbreviations within policy
- Signifor LAR – define abbreviations within policy
- Tecfidera – rename Dimethyl Fumarate
- Xenazine – rename Tetrabenazine
Preferred Drug List (PDL) Changes
December 2021. The following changes to the drug list are effective December 22, 2021:
Formulary Additions
- Amantadine oral solution add Tier 1
- Complete Natal DHA add Tier 3
- Eliquis starter pack add Tier 2
- Folivane-OB capsule add Tier 3
- HyperHep B immune globulin solution add Tier 3
- HyperTET S/D immune globulin solution add Tier 3
- Kinrix vaccine add Tier 0 (ACA limitations may apply)
- MenQuadfi vaccine add Tier 0 (ACA limitations may apply)
- Nabi-HB immune globulin solution add Tier 3
- Nascobal nasal spray add Tier 3 with medical necessity prior authorization
- Nebivolol tablet add Tier 1
- Octreotide solution add Tier 1 with SP and prior authorization
- Oxaydo tablet add Tier 3 with medical necessity prior authorization
- Pegasys solution add Tier 2 with SP and prior authorization
- Prevnar 20 vaccine add Tier 0 (ACA limitations may apply)
- PrismaSol solution add Tier 3
- Pulmozyme solution add Tier 3 with SP and prior authorization
- Taron-C DHA capsule add Tier 3
- Tepmetko tablet add Tier 3 with limited access, SP, quantity limit and prior authorization
- Triveen-Duo DHA add Tier 3
- Welireg tablet add Tier 3 with SP and prior authorization
Quantity Limit Update
- Update Quantity Limit
- Ajovy solution
- Emgality solution
- Add Quantity Limit
- Bydureon suspension
- Centany Ointment
- Mupirocin Ointment
Prior Authorization Update
- Add Prior Authorization (medical necessity)
- Ivermectin tablet
- Stromectol tablet
Tier Update
- Bystolic tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
December 2021. The following changes to the drug list are effective December 22, 2021:
Formulary Additions
- Amantadine solution add Tier 1
- Cefoxitin solution add Tier 1
- Ceftazidime solution add Tier 1
- Desonide gel add Tier 1 with medical necessity prior authorization
- Eliquis starter kit add Tier 2
- Kinrix add Tier 0 (ACA limitations may apply)
- Menactra solution add Tier 0 (ACA limitations may apply)
- MenQuadfi add Tier 0 (ACA limitations may apply)
- Nebivolol tablet add Tier 1
- Octreotide solution add Tier 4 with SP and prior authorization
- Pegasys solution add Tier 4 with SP and prior authorization
- Prevnar 20 vaccine add Tier 0 (ACA limitations may apply)
- Pulmozyme solution add Tier 4 with SP and prior authorization
- Tepmetko tablet add Tier 4 with SP, quantity limit and prior authorization
- Welireg tablet add Tier 4 with SP and prior authorization
Prior Authorization Update
- Add Prior Authorization (medical necessity)
- Ivermectin tablet
Quantity Limit Updates
- Update Quantity Limit
- Ajovy
- Emgality
- Add Quantity Limit
- Mupirocin ointment
Tier Updates
- Palonosetron solution
- Vancomycin IV solution
Removed from Formulary
- Androxy tablet
- Betaseron solution
- Bystolic tablet; consider metoprolol succinate, metoprolol tartrate, carvedilol, atenolol, nebivolol
- Dermasorb TA kit
- Stromectol tablet; consider ivermectin tablet (prior authorization required)
See the PacificSource Drug Lists page for the current drug list.