Updates on Existing Criteria
December 2022. The following changes to criteria are effective December 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Antihemophilic Factors – update criteria for hemophilia B
- Belimumab – update age restriction
- Bevacizumab – updated preferred product for all indications
- Enfuvirtide – updated age restriction and exclusion criteria
- Esriet – renamed pirfenidone and updated applicable drugs to only include generic products
- Orkambi – update dosing for ages 1 year and older
- Phesgo – updated appropriate treatment regimen
- Samsca – updated treatment regimen and exclusion criteria
- Serostim – updated appropriate treatment regimen
- Siponimod – updated required medical information and clarified exclusion criteria
- Spravato – updated age restriction
- Tarpeyo – clarified duration of therapy and updated approval duration
Preferred Drug List (PDL) Changes
December 2022. The following changes to the drug list are effective December 22, 2022:
Formulary Additions
- Bexarotene gel add Tier 1, SP, quantity limit and prior authorization
- Calquence tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Cometriq kit add Tier 3 with SP, quantity limit, partial fill and prior authorization
- Dyanavel XR chewable tablet add Tier 3 with quantity limit and prior authorization
- Everolimus soluble tablet add Tier 1 with SP, quantity limit and prior authorization
- Ezetimibe-Rosuvastatin tablet add Tier 3 with quantity limit
- Fluticasone HFA inhaler add Tier 2 with quantity limit
- Fluticasone-Vilanterol inhaler add Tier 2 with quantity limit
- Humalog insulin add Tier 3 with medical necessity prior authorization
- Insulin Degludec solution add Tier 3 with medical necessity prior authorization
- Insulin glargine add Tier 3 with medical necessity prior authorization
- Insulin lispro add Tier 3 with medical necessity prior authorization
- Lantus solution add Tier 2
- Novolog insulin add Tier 2
- Novolog Relion insulin add Tier 3 with medical necessity prior authorization
- Orkambi packet add Tier 3 with limited access, quantity limit and prior authorization
- Oseltamivir suspension add Tier 1 with quantity over time limit
- Pirfenidone tablet add Tier 1 with SP, quantity limit and prior authorization
- Ryaltris nasal suspension add Tier 3 with quantity limit and medical necessity prior authorization
- Sorafenib tablet add Tier 1 with SP, quantity limit and prior authorization
- Sotyktu tablet add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Theophylline elixir add Tier 1
Prior Authorization Updates
- Add Medical Necessity
- Esbriet tablet
- Imbruvica 70mg capsule
Quantity Limit
- Add quantity limit
- Kisqali Femara Pack
- Nubeqa tablet
- Xopenex nebulizer solution
- Update quantity limit
- Cometriq kit
- Methergine tablet
- Methylergonovine maleate tablet
- Pemazyre tablet
Tier Update
- Nexavar tablet
Removed from Formulary
- Hydromorphone suppository
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
December 2022. The following changes to the drug list are effective December 22, 2022:
Formulary Additions
- Bexarotene gel add Tier 4, SP, quantity limit and prior authorization
- Calquence tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Cometriq kit add Tier 4 with SP, quantity limit, partial fill and prior authorization
- Everolimus soluble tablet add Tier 4 with SP, quantity limit and prior authorization
- Fluticasone HFA inhaler add Tier 2 with quantity limit
- Fluticasone-Vilanterol inhaler add Tier 2 with quantity limit
- Insulin Degludec solution add Tier 3 with medical necessity prior authorization
- Insulin glargine add Tier 3 with medical necessity prior authorization
- Lantus solution add Tier 2
- Novolog insulin add Tier 2
- Novolog Relion insulin add Tier 3 with medical necessity prior authorization
- Orkambi packet add Tier 4 with limited access, quantity limit and prior authorization
- Oseltamivir suspension add Tier 1 with quantity over time limit
- Pirfenidone tablet add Tier 4 with SP, quantity limit and prior authorization
- Sorafenib tablet add Tier 4 with SP, quantity limit and prior authorization
- Theophylline elixir add Tier 1
Removed from Formulary
- Afinitor soluble tablet; consider everolimus soluble tablet
- Hydromorphone suppository
- Nexavar tablet; consider sorafenib tablet
- Tamiflu suspension; consider oseltamivir suspension
- Targretin gel; consider bexarotene gel
See the PacificSource Drug Lists page for the current drug list.