Updates on Existing Criteria:
February 2021. The following changes to criteria are effective February 22, 2021:
Preauthorization Criteria – Clinical Updates
- Ibrutinib – remove from General Oncology Agents Criteria with stand-alone criteria to include chronic graft versus host disease (GVHD) indication
- OPIOID Quantity Above Morphine Milligram Equivalents (MME) – MME threshold to be reduced to 200
Preauthorization Criteria – Clerical Updates
- Vpriv rename Velaglucerase Alfa
- Vimizim rename Elosulfase Alfa
- Self-Administered Drugs (SAD) – removed affected medications list and referred to package insert
Preferred Drug List (PDL) Changes
February 2021. The following changes to the drug list are effective February 22, 2021:
Formulary Additions
- Amicar oral solution add Tier 3
- Aminocaproic acid oral solution add Tier 1
- Deferiprone tablet add Tier 1 with SP, quantity limit and preauthorization
- Dificid oral suspension add Tier 3 with step therapy
- Efavirenz-lamivudine-tenofovir tablet add Tier 1
- Emtricitabine capsule add Tier 1
- Icosapent Ethyl capsule add Tier 1 with quantity limit and preauthorization
- Impeklo lotion add Tier 3 with medical necessity preauthorization
- PEG-KCL-NaCl-NaSulf-NA-Asc-C oral solution add Tier 0 (ACA drug, restrictions may apply)
- Qdolo solution add Tier with quantity limit and medical necessity preauthorization
- RediTrex prefilled solution add Tier 3 with medical necessity preauthorization
- Tavaborole solution add Tier 1 with medical necessity preauthorization
- Tolvaptan tablet add Tier 1 with SP and preauthorization
- Triderm cream add Tier 1
- Tyblume tablet add Tier 0 (ACA drug, restrictions may apply)
- Xerava solution add Tier 3
Quantity Limit Updates
- Ambien tablet
- Jatenzo capsule
- Qnasl nasal solution
- Venclexta tablet
- Wakix tablet
- Zolpidem tablet
Tier Updates
- Atripla tablet
- Emtriva capsule
- MoviPrep
- Symfi Lo tablet
- Symfi tablet
- Truvada tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
February 2021. The following changes to the drug list are effective February 22, 2021:
Formulary Additions
- Aminocaproic acid tablet add Tier 1
- Deferiprone tablet add Tier 4 with SP and preauthorization
- Dificid oral suspension add Tier 3 with step therapy
- Digoxin oral solution add Tier 1
- Efavirenz-lamivudine-tenofovir tablet add Tier 1
- Emtricitabine capsule add Tier 1
- Icosapent Ethyl capsule add Tier 1 with quantity limit and preauthorization
- NitroMist aerosol solution add Tier 3
- PEG-KCL-NaCl-NaSulf-NA-Asc-C oral solution add Tier 0 (ACA drug, restrictions may apply)
- Selzentry oral solution add Tier 2
- Tyblume tablet add Tier 0 (ACA drug, restrictions may apply)
Tier Update
- Moviprep
Update Quantity Limit
- Jatenzo capsule
- Venclexta tablet
- Zolpidem tablet
Removed from Formulary
- Atripla tablet; consider efavirenz-emtricitabine-tenofovir tablet
- Emtriva capsule; consider emtricitabine capsule
- Ferriprox tablet; consider deferiprone tablet
- Symfi Lo and Symfi tablet; consider efavirenz-lamivudine-tenofovir DF tablet
- Truvada tablet; consider emtricitabine-tenofovir disoproxil fumerate tablet
See the PacificSource Drug Lists page for the current drug list.