Updates on Existing Criteria
December 2024. The following changes to criteria are effective December 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – add Mounjaro and update required medical information
Stimulants – remove policy
January 2025. The following changes to criteria are effective January 22, 2025:
Prior Authorization Criteria – Clinical Updates
- Alglucosidase Alfa – update appropriate treatment and exclusion criteria
- Avalglucosidase Alfa-NGPT – update exclusion criteria and prescriber restriction
- Betibeglogene Autotemcel – update appropriate treatment
- Botox – update appropriate treatment
- Letermovir – update covered uses and age restriction
- Mannitol – replace existing policy with new policy called Inhaled Mannitol
- Olipudase Alfa – update covered uses and required medical information
- Opzelura – update required medical information, appropriate treatment, and exclusion criteria
- Parathyroid Hormone – replace existing policy with new policy for Yorvipath
- Primary Biliary Cholangitis Agents – add new drug Livdelzi and update appropriate treatment
- Proximal Complement Inhibitor – update covered uses, required medical information, and appropriate treatment
- Reblozyl – change policy name to Luspatercept-AAMT, update covered uses, required medication information, appropriate treatment, and prescriber restriction
- Sparsentan – update exclusion criteria and coverage duration
- Targeted Immune Modulators – update Tofidence and Tyenne intravenous to preferred medical drugs for rheumatoid arthritis and juvenile idiopathic arthritis
- Topical Dermatitis and Psoriatic Agents – update required medical information and appropriate treatment
Preferred Drug List (PDL) Changes
December 2024. The following changes to the drug list are effective December 22, 2024:
Prior Authorization
- Remove Medical Necessity
- Methadose solution
- Mounjaro injection
- Zubsolv tablet
Quantity Limit
- Update
- Buprenorphine tablet
- Buprenorphine-naloxone tablet and film
- Zubsolv tablet
Tier Update
- Mounjaro injection
January 2025. The following changes to the drug list are effective January 22, 2025:
Formulary Additions
- ACAM2000 vaccine add Tier 0 (ACA vaccine)
- Cobenfy capsule add Tier 3 with quantity limit and step therapy
- Femlyv tablet add Tier 0 (ACA limitations may apply)
- Lazcluse tablet add Tier 3 with SP, quantity limit, limited access, and prior authorization
- Livdelzi capsule add Tier 3 with SP, quantity limit, limited access, and prior authorization
- Tryvio tablet add Tier 3 with quantity limit and prior authorization
- Yorvipath injection add Tier 3 with SP, quantity limit, limited access, and prior authorization
Prior Authorization
- Add Medical Necessity
- Ibrance tablet and capsule
- Inderal LA capsule
- Kyzatrex capsule
Tazorac cream and gel
- Remove Medical Necessity
- Kisqali tablet
- Kisqali-Femara Co-pak
Removed from Formulary
- Natpara injection
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
December 2024. The following changes to the drug list are effective December 22, 2024:
Formulary Additions
- Mounjaro injection add Tier 2 with quantity limit and prior authorization
- Zubsolv tablet add Tier 3 with quantity limit
Quantity Limit
- Update
- Buprenorphine tablet
- Buprenorphine-naloxone tablet and film
January 2025. The following changes to the drug list are effective January 22, 2025:
Formulary Additions
- ACAM2000 vaccine add Tier 0 (ACA vaccine)
- Cobenfy capsule add Tier 3 with quantity limit and step therapy
- Femlyv tablet add Tier 0 (ACA limitations may apply)
- Glydo Gel syringe add Tier 1 with quantity limit
- Kisqali tablet add Tier 4 with SP, quantity limit, and prior authorization
- Kisqali Femara tablet add Tier 4 with SP, quantity limit, and prior authorization
- Lazcluse tablet add Tier 4 with SP, quantity limit, limited access, and prior authorization
- Livdelzi capsule add Tier 4 with SP, quantity limit, limited access, and prior authorization
- Tryvio tablet add Tier 3 with quantity limit and prior authorization
- Yorvipath injection add Tier 4 with SP, quantity limit, limited access, and prior authorization
Removed from Formulary
- Ibrance tablet and capsule; consider Verzenio and Kisqali tablets
- Kyzatrex capsule; consider testosterone solution and gel, Jatenzo capsule, Tlando capsule, and Androderm patch
- Natpara injection
- Tazorac cream and gel; consider tazarotene
See the PacificSource Drug Lists page for the current drug list.