Updates on Existing Criteria
February 2023. The following changes to criteria are effective February 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Alemtuzumab – update covered uses, required information for Secondary Progressive (SPMS)
- Alosetron – updated required prior treatment and diagnostic criteria
- Amifampridine – update to include pediatric indication
- Cystaran, Cystadrops – update required medical information and reauthorization criteria
- Dasatinib - updated appropriate treatment section
- Emsam – update appropriate treatment regimen and remove required medical information except diagnosis
- Endothelin Receptor Antagonists – update required medical information
- Hyaluronic Acid Derivatives – renamed NON-Preferred Hyaluronic Acid Derivatives and removed preferred Synvisc/Synvisc One/Orthovisc from criteria
- Intravitreal Anti-VEGF Therapy – add Cimerli as preferred product, move Byooviz to preferred and move Eylea to non-preferred
- Leuprolide – update required medical information for treatment of endometriosis
- Long Acting Injectable Risperidone – update covered uses and required medical information, added exclusion of dementia related psychosis and prior hypersensitivity
- Lusutrombopag – update reauthorization criteria
- Nilotinib – updated appropriate treatment section
- Northera – rename Droxidopa and update required medical information, reauthorization criteria and coverage duration
- Nuplazid - added prescriber restriction
- Oncology Agents – add Imjudo, Tecvayli
- Orenitram – update required medical information and appropriate treatment regimen
- Oxlumo – rename Lumasiran and update to include reference lab values
- Ponvory – update required medical information
- Rayaldee – rename Calcifediol and update covered uses and required medical information
- Selumetinib – replace format of criteria
- Sensipar – rename Cinacalcet and update covered uses and required medical information
- Solriamfetol – update covered uses and include baseline Epworth Sleepiness Scale (ESS) for Narcolepsy
- Targeted Immune Modulators – add quantity limit for Rinvoq for use in non-radiographic axial spondyloarthritis
- Tedizolid – Update appropriate treatment and remove exclusions
- Teriflunomide – update covered uses and required medical information
- Tolvaptan – replaces current Samsca and Jynarque policies
- Verteporfin – update preferred products to Cimerli and Byooviz
- Xifaxan – update appropriate treatment regimen
- Yonsa – added prescriber restriction
- Zorbtive – update exclusion criteria and age restriction
Preferred Drug List (PDL) Changes
February 2023. The following changes to the drug list are effective February 22, 2023:
Formulary Additions
- Allopurinol tablet add Tier 3 with medical necessity prior authorization
- Dabigatran etexilate mesylate capsule add Tier 1 with quantity limit
- Roflumilast tablet add Tier 1 with quantity limit
Prior Authorization
- Add Medical Necessity
- Motofen tablet
- Northera capsule
- Pamelor capsule
- Samsca tablet
- Sensipar tablet
- Add Prior Authorization
- Synarel solution
Quantity Limit
- Remove Quantity Limit
- Omeprazole capsule
- Prilosec capsule
- Protonix tablet
- Prilosec capsule
- Add Quantity Limit
- Cotellic tablet
- Firdapse tablet
- Vemlidy tablet
- Quantity Limit Updates
- Adderall XR capsule
- Amphetamine-dextroamphetamine ER capsule
- Dexmethylphenidate ER capsule
- Dexmethylphenidate tablet
- Focalin tablet
- Focalin XR capsule
- Lansoprazole capsule
- Lyrica capsule
- Pregabalin capsule
- Prevacid capsule
Tier Update
- Synarel solution
Remove from Formulary
- Sylatron kit
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
February 2023. The following changes to the drug list are effective February 22, 2023:
Formulary Additions
- Dabigatran etexilate mesylate capsule add Tier 1 with quantity limit
- Roflumilast tablet add Tier 1 with quantity limit
- Vemlidy tablet add Tier 3 with quantity limit and prior authorization
Quantity Limit
- Remove Quantity Limit
- Omeprazole capsule
- Pantoprazole tablet
- Add Quantity Limit
- Cotellic tablet
- Firdapse tablet
- Quantity Limit Updates
- Amphetamine-dextroamphetamine ER capsule
- Dexmethylphenidate ER capsule
- Dexmethylphenidate tablet
- Lansoprazole capsule
- Pregabalin capsule
Tier Update
- Synarel solution
Prior Authorization addition
- Synarel solution
Removed from Formulary
- Lotronex tablet; consider alosetron tablet
- Daliresp tablet; consider roflumilast tablet
See the PacificSource Drug Lists page for the current drug list.