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January 2021 Drug List Change Notification

Updates on Existing Criteria:

January 2021. The following changes to criteria are effective January 22, 2021:

Preauthorization Criteria – Clinical Updates

  • Intron-A – Update to include compendia supported indication of Hypereosinophilic syndrome (HES)
  • Mepolizumab – Update to include new indication of Hypereosinophilic syndrome (HES)
  • Remodulin – Update required medical information for pulmonary arterial hypertension
  • Targeted Immune Modulators – Update to include new indication (Juvenile Idiopathic Arthritis) for Xeljanz and Simponi Aria
  • Tysabri – rename Natalizumab and update criteria for Crohn’s Disease
  • Tyvaso – Update required medical information for pulmonary arterial hypertension
  • Xgeva – rename Denosumab and update appropriate treatment regimen
  • Xofigo – remove stand-alone policy and add to General Oncology Agent criteria
  • Zorbtive – update coverage duration

Preauthorization Criteria – Clerical Updates

  • Ultomiris – rename Ravulizumab
  • Yescarta – rename Axicabtagene ciloleucel

Preferred Drug List (PDL) Changes

January 2021. The following changes to the drug list are effective January 22, 2021:

Formulary Additions

  • Alkindi sprinkle capsule add Tier 3 with SP, quantity limit and preauthorization
  • Conjupri tablet add Tier 3 with quantity limit and medical necessity preauthorization
  • Epclusa tablet add Tier 3 with SP, quantity limit and medical necessity preauthorization
  • Lampit tablet add Tier 3 with quantity over time limit and medical necessity preauthorization
  • MenQuadfi conjugate vaccine add Tier 0 (ACA limitations apply)
  • Monoferric intravenous solution add Tier 3
  • Trelegy Ellipta add Tier 2 with quantity limit
  • Xywav oral solution add Tier 3 with SP, quantity limit and preauthorization

Preauthorization Update

  • Zoladex implant – add preauthorization

Quantity Limit Updates

  • Xyrem oral solution
  • Zoladex implant

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes

January 2021. The following changes to the drug list are effective January 22, 2021:

Formulary Additions

  • Alkindi Sprinkle capsule add Tier 4 with SP, quantity limit and preauthorization
  • Dimethyl Fumarate Delayed Release capsule starter pack add Tier 3 with SP, quantity limit and preauthorization
  • MenQuadfi conjugate vaccine add Tier 0 (ACA limitations apply)
  • Sevenfact intravenous solution add Tier 4 with SP and preauthorization
  • Theo-24 extended release capsule add Tier 3 with quantity limit
  • Trelegy Ellipta add Tier 2 with quantity limit
  • Xywav oral solution add Tier 4 with SP, quantity limit and preauthorization

Quantity Limit Addition

  • Xyrem oral solution

Tier Update

  • Repatha prefilled syringe
  • Repatha Pushtronex system
  • Repatha SureClick

Removed from Formulary

  • Tecfidera capsule; consider dimethyl fumarate delayed release capsule

See the PacificSource Drug Lists page for the current drug list.