Updates on Existing Criteria
February 2022. The following changes to criteria are effective February 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Abemaciclib – update to include new breast cancer indication including coverage for Ki-67 biomarker
- Intravitreal Anti-VEGF Therapy – add new drug Susvimo as non-preferred product
- Dupilumab – update to include new 100mg strength and new age approval for 6 years and older for asthma
- Tecartus – update to include new indication of relapsed and refractory acute lymphoblastic leukemia
- Cerdelga – rename Eliglustat and update required medical information
- Oncology Agents – remove Tivdak and add stand-alone policy
- Xifaxan – update exclusion criteria
- Imiglucerase – update required medical information to include diagnosis confirmed by enzyme assay
Preferred Drug List (PDL) Changes
February 2022. The following changes to the drug list are effective February 22, 2022:
Additions
- APO-Varenicline tablet add Tier 0 (ACA limitations may apply) with quantity over time limit
- Benefix kit add Tier 3 with SP and prior authorization
- Biktarvy tablet add Tier 2 with quantity limit
- Dupixent solution add Tier 3 with SP, quantity limit and prior authorization
- Eprontia solution add Tier 3 with quantity limit and medical necessity prior authorization
- Opzelura cream add Tier 3 with quantity over time limit and prior authorization
- Scemblix tablet add Tier 3 with SP, quantity limit and prior authorization
- Sertraline capsule add Tier 3
- Tavneos capsule add Tier 3 with SP, quantity limit and prior authorization
- Tyrvaya nasal solution add Tier 3 with quantity limit and medical necessity prior authorization
- Varenicline tablet add Tier 0 (ACA limitations may apply) with quantity over time limit
Prior Authorization Updates
- Add Prior Authorization
- Ozempic solution
- Rybelsus tablet
- Trulicity solution
- Victoza solution
Step Therapy Updates
- Remove Step Therapy
- Ozempic solution
- Rybelsus tablet
- Trulicity solution
- Victoza solution
Quantity Limit Updates
- Update Quantity Limit
- Dupixent solution
- Ambien CR 6.25mg tablet
- Zolpidem 6.25mg extended release tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
February 2022. The following changes to the drug list are effective February 22, 2022:
Formulary Additions
- APO-Varenicline tablet add Tier 0 (ACA limitations may apply) with quantity over time limit
- Biktarvy tablet add Tier 2 with quantity limit
- Dupixent solution add Tier 4 with SP, quantity limit and prior authorization
- Opzelura cream add Tier 3 with quantity over time limit and prior authorization
- Scemblix tablet add Tier 4 with SP, quantity limit and prior authorization
- Tavneos capsule add Tier 4 with SP, quantity limit and prior authorization
- Varenicline tablet add Tier 0 (ACA limitations may apply) with quantity over time limit
Prior Authorization Updates
- Add Prior Authorization
- Ozempic solution
- Rybelsus tablet
- Trulicity solution
- Victoza solution
Step Therapy Updates
- Remove Step Therapy
- Ozempic solution
- Rybelsus tablet
- Trulicity solution
- Victoza solution
Quantity Limit Updates
- Update Quantity Limit
- Dupixent solution
- Zolpidem 6.25mg extended release tablet
See the PacificSource Drug Lists page for the current drug list.