Updates on Existing Criteria
December 2024. The following changes to criteria are effective December 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Cerliponase Alfa – update covered uses and age restriction
- Continuous Glucose Monitors – update appropriate treatment and exclusion criteria
- Daprodustat – rename “Hypoxia-Inducible Factor Proplyl Hydroxylase (HIF PH) Inhibitors” and add new drug Vafseo
- Medical Necessity – add new drugs Vigafyde, Onyda XR, and Crexont
- Oncology Agents – add new drug Voranigo
- Palforzia – update appropriate treatment and age restriction
- Targeted Immune Modulators – update quantity limitations
Preferred Drug List (PDL) Changes
December 2024. The following changes to the drug list are effective December 22, 2024:
Formulary Additions
- Crexont capsule add Tier 3 with medical necessity prior authorization
- Neffy nasal spray add Tier 3 with quantity limit
- Nemluvio auto-injector add Tier 3 with SP, quantity limit, and prior authorization
- Onyda XR suspension add Tier 3 with medical necessity prior authorization
- Vafseo tablet add Tier 3 with SP, quantity limit, limited access, and medical necessity prior authorization
- Vigafyde solution add Tier 3 with quantity limit, limited access, and medical necessity prior authorization
- Voranigo tablet add Tier 3 with SP, quantity limit, limited access, and prior authorization
Removed from Formulary
- Chlorpropamide tablet
- Oxbryta tablet
- Tolazamide tablet
- Tolbutamide tablet
Legacy Enhanced Drug List Removals
- Corzide tablet
- Digitek tablet
- Digox tablet
- Elixophyllin elixir
- Flovent diskus
- Livalo tablet
- Nadolol-Bendroflumethiazide tablet
- Niacor tablet
- Nitro-Dur patch
- Nitrolingual spray
- Norpace capsule
- Prevalite powder and packet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
December 2024. The following changes to the drug list are effective December 22, 2024:
Formulary Additions
- Bepreve solution add Tier 3
- Neffy nasal spray add Tier 3 with quantity limit
- Nemluvio auto-injector add Tier 4 with SP, quantity limit, and prior authorization
- Voranigo tablet add Tier 4 with SP, quantity limit, limited access, and prior authorization
Removed from Formulary
- Chlorpropamide tablet
- Oxbryta tablet
- Tolazamide tablet
- Tolbutamide tablet
Tier Update
- Sofosbuvir-Velpatasvir tablet
See the PacificSource Drug Lists page for the current drug list.