Updates on Existing Criteria
February 2024. The following changes to criteria are effective February 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Afinitor – update required medical information for diagnosis of Tuberous Sclerosis Complex (TSC)
- Belinostat – remove stand alone policy and add to Oncology Agents criteria
- Belzutifan – update required medical information and exclusion criteria
- Betaine – update required medical information and appropriate treatment regimen
- Carglumic Acid – update duration of treatment allowed for acute hyperammonemia
- Cysteamine – update covered uses and required medical information
- Eliglustat - update covered uses and prescriber restriction
- Epoprostenol – update covered uses, required medical information, coverage duration and remove age restriction
- Hereditary Tyrosinemia (HT-1) – update covered uses and remove dosing
- Hormone Supplementation under 18 years of age – update criteria for gender dysphoria
- Hydrocortisone Oral Granules – update appropriate treatment regimen including dose and reauthorization criteria
- Iloprost – update required medical information and reauthorization criteria
- Imiglucerase – update covered uses and required medical information
- Larotrectinib – update diagnostic requirement and reauthorization criteria
- Lumasiran – update required medical information and appropriate treatment regimen
- Mechlorethamine – remove stand alone policy
- Melphalan – remove stand alone policy and add to Oncology Agents criteria
- Metreleptin – update covered uses and appropriate treatment regimen
- Myeloid Growth Factors – update Ziextenzo as a non-preferred product
- Nulibry – update appropriate treatment regimen
- Oncology Agents – add Fruzaqla tablet, Beleodaq, Evomela
- Oral Testosterone – update covered uses and include gender dysphoria
- Orenitram – update covered uses and required medical information
- Osilodrostat – update required medical information and criteria format
- Pretomanid – update prescriber restriction
- Remodulin – update covered uses and required medical information
- Riociguat – update covered uses and appropriate treatment regimen
- Signifor – update required medical information and exclusion criteria
- Signifor LAR – update required medical information and covered uses
- Taliglucerase – update prescriber restriction
- Targeted Immune Modulators – Update to include Enbrel new indication of Juvenile Psoriatic Arthritis (JPsA) and Cosentyx new indication of Hidradenitis Suppurativa (HS)
- Targretin – remove stand alone policy
- Thalidomide – update covered uses and appropriate treatment regimen
- Topical Antipsoriatics – update age restriction for Zoryve and update covered uses
- Turalio – update appropriate treatment and exclusion criteria
- Tyvaso – update covered uses and required medical information
- Vaginal Progesterone – update covered uses and required medical information
- Velaglucerase Alfa – update covered uses and required medical information
- Vosoritide – update required medical information and age restriction
- Weight Loss Prior Authorization Criteria (for select large groups) – update to include Zepbound
- Xifaxan – update covered uses
- Xuriden – update required medical information including diagnostic criteria and reauthorization criteria
- Zavesca – update covered uses and required medical information
Preferred Drug List (PDL) Changes
February 2024. The following changes to the drug list are effective February 22, 2024:
Formulary Additions
- Bexagliflozin add Tier 3 with medical necessity prior authorization
- Bimzelx solution add Tier 3 with SP and medical necessity prior authorization
- Entyvio solution pen-injector add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Freestyle Libre Reader add Tier 2 with quantity over time limit and prior authorization
- Fruzaqla capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
- Likmez suspension add Tier 3 with medical necessity prior authorization
- M-Natal Plus tablet add Tier 0 for females ages 15-50 years
- Motpoly XR capsule add Tier 3 with quantity limit and medical necessity prior authorization
- M-Vit tablet add Tier 0 for females ages 15-50 years
- Niva-Plus tablet add Tier 0 for females ages 15-50 years
- O-Cal FA tablet add Tier 0 for females ages 15-50 years
- Omvoh solution add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Opfolda capsule add Tier 3 with SP, quantity limit and prior authorization
- Pazopanib tablet add Tier 1 with SP, quantity limit and prior authorization
- PNV Prenatal Plus tablet add Tier 0 for females ages 15-50 years
- Prenatal Plus tablet add Tier 0 for females ages 15-50 years
- Prenatal tablet add Tier 0 for females ages 15-50 years
- ProChamber VHC device add Tier 3
- Rozlytrek packet add Tier 3 with SP, quantity limit and prior authorization
- Teriparatide solution add Tier 1 with SP and prior authorization
- Velsipity tablet add Tier 3 with SP, quantity limit and medical necessity prior authorization
Tier Update
- Flovent Diskus
- Mydayis capsule
- Vyvanse capsule
- Vyvanse chewable tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
February 2024. The following changes to the drug list are effective February 22, 2024:
Formulary Additions
- Everolimus tablet add Tier 1 with quantity limit
- Freestyle Libre reader add Tier 2 with quantity over time and prior authorization
- Fruzaqla capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
- M-Natal Plus tablet add Tier 0 for females ages 15-50 years
- M-Vit tablet add Tier 0 for females ages 15-50 years
- Niva-Plus tablet add Tier 0 for females ages 15-50 years
- O-Cal FA tablet add Tier 0 for females ages 15-50 years
- Opfolda capsule add Tier 4 with SP, quantity limit and prior authorization
- Pazopanib tablet add Tier 4 with SP, quantity limit and prior authorization
- PNV Prenatal Plus tablet add Tier 0 for females ages 15-50 years
- Prenatal Plus tablet add Tier 0 for females ages 15-50 years
- Prenatal tablet add Tier 0 for females ages 15-50 years
- ProChamber VHC device add Tier 3
- Rozlytrek packet add Tier 4 with SP, quantity limit and prior authorization
- Teriparatide solution add Tier 4 with SP and prior authorization
Removed from Formulary
- Forteo solution; consider teriparatide solution
- Mydayis capsule; consider amphetamine-dextroamphetamine extended release (ER) capsule, dextroamphetamine sulfate ER capsule, dexmethylphenidate ER capsule, lisdexamfetamine, methylphenidate ER (CD) capsule, methylphenidate ER (LA) capsule, methylphenidate ER tablet (18mg, 27mg, 36mg, 54 mg)
- Votrient tablet; consider pazopanib tablet
- Vyvanse capsule and chewable tablet; consider lisdexamfetamine capsule, amphetamine-dextroamphetamine extended release (ER) capsule, dextroamphetamine sulfate ER capsule, dexmethylphenidate ER capsule, methylphenidate ER (CD) capsule, methylphenidate ER (LA) capsule, methylphenidate ER tablet (18mg, 27mg, 36mg, 54 mg)
- Zortress tablet; consider everolimus tablet
See the PacificSource Drug Lists page for the current drug list.