Updates on Existing Criteria
December 2023. The following changes to criteria are effective December 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Afamelanotide – remove current policy and update format
- CGRP Inhibitors – remove current criteria, update format and include coverage for Nurtec and Qulipta
- Continuous Glucose Monitors – update coverage duration and add Freestyle Libre 3 to coverage
- Crizanlizumab – add dose rounding requirement
- Dupilumab – remove current criteria, update format and appropriate treatment criteria
- Elagolix – remove current policy and update format
- Endothelin Receptor Antagonists – update covered uses and required medical information
- Givosiran – update covered uses
- Growth Hormones – update to include Ngenla
- Immune Globulin – update initial approval criteria for PANDAS diagnosis
- Intravitreal Complement Inhibitors – update to include Izervay coverage
- Kuvan – rename Sapropterin, update required medical information and update reauthorization criteria
- Non-Preferred Medical Drug Codes – to include non-preferred codes for bortezomib and pemetrexed
- Nusinersen – update required medical information and remove dosing section
- Onasemnogene Abeparvovec XIOI - update required medical information and reauthorization criteria
- Oncology Agents – add Talvey, Vanflyta; remove abiraterone, imatinib, bortezomib, Velcade (bortezomib), pemetrexed, Pemfexy (pemetrexed), Alimta (pemetrexed disodium)
- Orgovyx – update covered uses and remove dosage
- Oteseconazole – remove allowed dosing section
- Palivizumab – update to require step through Beyfortus for coverage
- Palynziq – update covered uses and required medical information
- Phenoxybenzamine – remove dosing information
- Phosphodiesterase-5 (PDE-5) Enzyme Inhibitors For Pulmonary Arterial Hypertension – update required medical information
- Risdiplam – update required medical information and reauthorization criteria
- Serostim – update required medical information and reauthorization requirement
- Stiripentol – update covered uses and remove standard dosing
- Subcutaneous Immune Globulin – update required medical information
- Sutimlimab – update covered uses and reauthorization criteria
- Tagraxofusp-ERZS – update covered uses and required medical information
- Triptorelin – update required medical information and coverage for gender dysphoria
Step Therapy Criteria – Clinical Updates
- Antidepressants - update vilazodone tablet to step 1 and remove Viibryd tablet (including starter pack)
- Atypical Antipsychotics – update lurasidone tablet to step 1 and remove Latuda tablet
- Prostaglandins Ophthalmic – remove step therapy policy
Preferred Drug List (PDL) Changes
December 2023. The following changes to the drug list are effective December 22, 2023:
Formulary Additions
- Beyfortus prefilled syringe add Tier 0
- Breo Ellipta inhalation add Tier 3 with quantity limit
- Brimonidine tartrate ophthalmic solution add Tier 1
- Dimethyl fumarate starter pack add Tier 3 with SP and quantity limit
- Dorzolamide-timolol ophthalmic solution add Tier 1
- Iyuzeh ophthalmic solution add Tier 3 with quantity limit
- Methotrexate tablet add Tier 1
- Ngenla solution pen injector add Tier 3 with SP and prior authorization
- Opvee nasal solution add Tier 2 with quantity over time limit
- Oxybutynin solution add Tier 1
- Tecfidera starter pack add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Tretinoin microsphere 0.08% gel add Tier 1 with medical necessity prior authorization
- Vanflyta tablet add Tier 3 with SP, limited access and prior authorization
- Xdemvy ophthalmic solution add Tier 3 with SP, quantity over time limit and prior authorization
- Ycanth solution add Tier 3 with quantity limit and prior authorization
Quantity Limit
- Add quantity limit
- Elmiron capsule
- Onglyza tablet
- Saxagliptin tablet
- Update quantity limit
- Restoril capsule
- Temazepam capsule
- Zelboraf tablet
- Remove quantity limit
- Aripiprazole tablet
Prior Authorization
- Remove medical necessity
- Nurtec tablet
- Qulipta tablet
- Add medical necessity
- Copaxone solution
- Latuda tablet
- Remove prior authorization
- Abiraterone tablet
- Glatiramer acetate solution
- Glatopa solution
- Imatinib tablet
Step Therapy
- Step Therapy removal
- Latuda tablet
- Viibryd tablet
- Step Therapy update
- Lurasidone tablet
- Vilazodone tablet
Tier Update
- Emend oral suspension
- Intron A
- Pegasys solution
- Peg-Intron kit
- Peg-Intron Redipen
- Pred Mild ophthalmic suspension
- Savella tablet
- Serevent Diskus
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
December 2023. The following changes to the drug list are effective December 22, 2023:
Formulary Additions
- Abiraterone tablet add Tier 4 with SP and partial fill
- Aripiprazole oral solution
- Beyfortus prefilled syringe add Tier 0
- Dimethyl fumarate starter pack add Tier 3 with SP and quantity limit
- Glatiramer solution add Tier 3 with SP and quantity limit
- Methotrexate tablet add Tier 1
- Ngenla solution pen injector add Tier 4 with SP and prior authorization
- Nurtec dispersible tablet add Tier 3 with quantity limit and prior authorization
- Opvee nasal solution add Tier 2 with quantity over time limit
- Oxybutynin solution add Tier 1
- Qulipta tablet add Tier 3 with quantity limit and prior authorization
- Saxagliptin tablet add Tier 1 with quantity limit
- Vanflyta tablet add Tier 4 with SP, limited access and prior authorization
- Xdemvy ophthalmic solution add Tier 4 with SP, quantity over time limit and prior authorization
- Ycanth solution add Tier 3 with quantity limit and prior authorization
Quantity Limit
- Add quantity limit
- Elmiron capsule
- Remove quantity limit
- Aripiprazole tablet
- Update quantity limit
- Sumatriptan succinate auto injector
- Temazepam capsule
- Zelboraf tablet
Step Therapy
- Remove Step Therapy
- Bimatoprost solution
- Latanoprost solution
- Lumigan solution
- Lurasidone tablet
- Tafluprost solution
- Travoprost solution
- Vilazodone tablet
Tier Update
- Dilantin 30mg capsule
Prior Authorization Removal
- Abiraterone tablet
- Imatinib tablet
Removed from Formulary
- Copaxone solution; consider glatiramer solution, glatopa solution
- Viibryd starter pack; consider vilazodone tablet
See the PacificSource Drug Lists page for the current drug list.