Updates on Existing Criteria
January 2025. The following changes to criteria are effective January 22, 2025:
Prior Authorization Criteria – Clinical Updates
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – add liraglutide
- Migraine Agents (Step Therapy) – add Reyvow as a step 2 drug and update step therapy requirement
February 2025. The following changes to criteria are effective February 22, 2025:
Prior Authorization Criteria – Clinical Updates
- Adenosine Deaminase (ADA) Replacement – update appropriate treatment and coverage duration
- Afamelanotide – update covered uses, required medical information, and appropriate treatment
- Alpha-1 Proteinase Inhibitors - update required medical information and appropriate treatment
- Antithrombin Alfa – update with new policy “Antithrombin III”
- Antithymocyte Globulins – update and combine “Antithymocyte Globulin” and “Thymoglobulin” to one policy
- Asciminib – update required medical information and appropriate treatment
- Belimumab - update required medical information and appropriate treatment
- Benralizumab – add new indication for eosinophilic granulomatosis with polyangiitis (EGPA)
- Calcitonin Gene-Related Peptide (CGRP) Inhibitors – update appropriate treatment
- Carglumic Acid – update covered uses, required medical information, appropriate treatment, exclusion criteria, and coverage duration
- Coagadex - update required medical information and appropriate treatment
- Crizanlizumab – update required medical information, appropriate treatment, and exclusion criteria
- Dinutuximab - update required medical information and appropriate treatment
- Dupilumab – add new indication for chronic obstructive pulmonary disease (COPD) and update age restriction
- Givosiran – update required medical information, appropriate treatment, exclusion criteria, and age restriction
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – remove Victoza
- Hormone Supplementation Under 18 Years of Age – update covered uses
- Intravitreal Anti-VEGF Therapy – add new biosimilar drug Pavblu
- Mavacamten – update required medical information, appropriate treatment, and coverage duration
- Metreleptin - update required medical information, appropriate treatment, and age restriction
- Miglustat – update required medical information and appropriate treatment
- Migraine Agents (Step Therapy) – remove Ubrelvy as a step 2 drug
- Nulibry – update required medical information, appropriate treatment, and coverage duration
- Ocrelizumab – add new drug Ocrevus Zunovo and update appropriate treatment
- Ofev – update required medical information, appropriate treatment, and exclusion criteria
- Oncology Agents – add new drug Tecentriq Hybreza
- Phosphodiesterase-5 (PDE-5) Enzyme Inhibitors for Pulmonary Arterial Hypertension – update appropriate treatment and exclusion criteria
- Pirfenidone – update required medical information, appropriate treatment, and exclusion criteria
- Ryplazim - update required medical information, appropriate treatment, and prescriber restriction
- Somatostatin Analogs - update required medical information and appropriate treatment
- Targeted Immune Modulators – add Tremfya to preferred pharmacy and medical drugs for ulcerative colitis
- Testosterone – update and combine “Oral Testosterone” and “Testopel” to one policy
- Ublituximab-xiiy – update appropriate treatment and exclusion criteria
- Vaginal Progesterone – update required medical information
Preferred Drug List (PDL) Changes
January 2025. The following changes to the drug list are effective January 22, 2025:
Prior Authorization
- Remove Medical Necessity
- Liraglutide injection
- Reyvow tablet
Step Therapy
- Add
- Reyvow tablet
Tier Update
February 2025. The following changes to the drug list are effective February 22, 2025:
Formulary Additions
- Aqneursa packet add Tier 3 with SP, quantity limit, limited access, and prior authorization
- Azmiro injection add Tier 3 with quantity limit and medical necessity prior authorization
- Dasatinib tablet add Tier 3 with SP, quantity limit, and new start only prior authorization
- Ebglyss injection add Tier 3 with SP, quantity limit, and medical necessity prior authorization
- Erzofri injection add Tier 3 with quantity limit and medical necessity prior authorization
- Hympavzi injection add Tier 3 with SP, quantity limit, and prior authorization
- Itovebi tablet add Tier 3 with SP, quantity limit, and prior authorization
- Jylamvo solution add Tier 3 with medical necessity prior authorization
- Lumakras 240 mg tablet add Tier 3 with SP, quantity limit, partial fill, and prior authorization
- Miplyffa capsules add Tier 3 with SP, quantity limit, limited access, and prior authorization
- Tremfya 200 mg/2 mL injection add Tier 3 with SP, quantity limit, and prior authorization
- Zituvimet tablet add Tier 3 with medical necessity prior authorization
Prior Authorization
- Add Medical Necessity
- Ciloxan ophthalmic ointment and solution
- Ebglyss injection
- Emflaza tablet
- Erzofri injection
- Jylamvo solution
- Plaquenil tablet
- Ubrelvy tablet
- Victoza injection
Zituvimet tablet
Removed from Formulary
- Estropipate tablet
- Keflex capsule
Quantity Limit
- Update
- Pirfenidone tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
January 2025. The following changes to the drug list are effective January 22, 2025:
Formulary Additions
- Liraglutide injection add Tier 2 with quantity limit and prior authorization
- Reyvow tablet add Tier 2 with quantity limit and step therapy
February 2025. The following changes to the drug list are effective February 22, 2025:
Formulary Additions
- Aqneursa packet add Tier 4 with SP, quantity limit, limited access, and prior authorization
- Dasatinib tablet add Tier 4 with SP, quantity limit, and new start only prior authorization
- Hympavzi injection add Tier 4 with SP, quantity limit, and prior authorization
- Itovebi tablet add Tier 4 with SP, quantity limit, and prior authorization
- Lumakras 240 mg tablet add Tier 4 with SP, quantity limit, partial fill, and prior authorization
- Miplyffa capsule add Tier 4 with SP, quantity limit, limited access, and prior authorization
- Tremfya 200 mg/2 mL injection add Tier 4 with SP, quantity limit, and prior authorization
Removed from Formulary
- Estropipate tablet
- Ubrelvy tablet; consider almotriptan tablet, eletriptan tablet, naratriptan tablet, sumatriptan (tablet, solution, and injection), rizatriptan tablet, zolmitriptan (tablet and solution), frovatriptan tablet, Reyvow tablet
- Victoza injection; consider liraglutide injection, Rybelsus tablet, Ozempic injection, Trulicity injection, and Mounjaro injection
Quantity Limit
- Update
- Pirfenidone tablet
See the PacificSource Drug Lists page for the current drug list.