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January 2022 Drug List Change Notification

Updates on Existing Criteria

January 2022. The following changes to criteria are effective January 22, 2022:

Prior Authorization Criteria – Clinical Updates

  • Belumosudil – remove stand-alone policy and add to general Oncology Agents criteria
  • Benralizumab – update required baseline eosinophil count for diagnosis of severe eosinophilic asthma
  • Growth Hormones (somatropin) injectables – adding Skytrofa with criteria for use and update preferred product to Norditropin
  • Histrelin – age restriction update
  • Hyaluronic Acid Derivatives – add non-preferred Synojoynt
  • Ibrutinib – remove stand alone policy and add to general Oncology Agents criteria
  • Invega Trinza – rename Invega Injectables and add new formulation (Invega Hafyera) criteria to policy
  • Nilotinib – update required medical information
  • Omalizumab – add criteria for new indication of nasal polyps
  • Targeted Immune Modulators – define Humira quantity limits with dosing

Prior Authorization Criteria – Clerical Updates

  • Makena – rename Hydroxyprogesterone Caproate
  • Mechlorethamine – clerical update for age restriction
  • Sotrovimab – remove policy (inactive drug)

 

Preferred Drug List (PDL) Changes

January 2022. The following changes to the drug list are effective January 22, 2022:

Formulary Additions

  • Cuvitru solution add Tier 3 with SP and prior authorization
  • Exkivity capsule add Tier 3 with SP and prior authorization
  • Insulin Glargine-yfgn solution add Tier 3 with medical necessity prior authorization
  • Invega Hafyera add Tier 3 with prior authorization
  • Invega Sustenna add Tier 3 with step therapy
  • Invega Trinza add Tier 3 with prior authorization
  • Invega Trinza add Tier 3 with prior authorization
  • Livmarli solution add Tier 3 with quantity limit and prior authorization
  • Loreev XR capsule add Tier 3 with medical necessity prior authorization
  • Lybalvi tablet add Tier 3 with quantity limit and medical necessity prior authorization
  • Novopen Echo device add Tier 3 with quantity over time limit
  • Opzelura cream add Tier 3 with medical necessity prior authorization
  • Qulipta tablet add Tier 3 with medical necessity prior authorization
  • Semglee (yfgn) solution add Tier 3 with medical necessity prior authorization
  • Skytrofa cartridge add Tier 3 with SP and prior authorization
  • Trudhesa nasal solution add Tier 3 with quantity over time limit and medical necessity prior authorization
  • Vaxneuvance vaccine add Tier 0 (ACA limitations may apply)

Quantity Limit Update

  • Update Quantity Limit
    • Modafinil tablet
    • Provigil tablet
  • Remove Quantity Limit
    • Amlodipine-Olmesartan tablet
    • Cymbalta capsule
    • Duloxetine capsule
    • Olmesartan tablet
    • Olmesartan-HCTZ tablet

Prior Authorization Update

  • Remove Prior Authorization (medical necessity)
    • Mefenamic Acid capsule

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

 

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

January 2022. The following changes to the drug list are effective January 22, 2022:

Formulary Additions

  • Cuvitru solution add Tier 4 with SP and prior authorization
  • Exkivity capsule add Tier 4 with SP, quantity limit and prior authorization
  • Insulin Glargine-yfgn solution add Tier 3 with medical necessity prior authorization
  • Livmarli solution add Tier 4, with SP, quantity limit and prior authorization
  • NovoPen Echo device add Tier 3 with quantity over time limit
  • Semglee (yfgn) solution add Tier 3 with medical necessity prior authorization
  • Skytrofa cartridge add Tier 4 with SP and prior authorization
  • Vaxneuvance vaccine add Tier 0 (ACA limitations may apply)

Prior Authorization Update

  • Remove Prior Authorization
    • Mefenamic acid capsule

Quantity Limit Updates

  • Update Quantity Limit
    • Modafinil tablet
  • Remove Quantity Limit
    • Amlodipine-Olmesartan tablet
    • Olmesartan tablet
    • Olmesartan-HCTZ tablet

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