July 2024 Drug List Change Notification (Commercial)

May 17, 2024

Updates on Existing Criteria

July 2024. The following changes to criteria are effective July 22, 2024:

Prior Authorization Criteria – Clinical Updates

Benralizumab – update required medical information
Bezlotoxumab – update covered uses, appropriate treatment and age restriction
Botox – update covered uses and appropriate treatment
Diroximel Fumarate – update appropriate treatment
Eliglustat, Imiglucerase, Taliglucerase, Velaglucerase Alfa – combine to Enzyme Replacement Therapy (ERT) For Gaucher Disease Type 1
Elosulfase Alfa, Galsulfase, Idursulfase, Laronidase, Vestronidase Alfa – combine to Mucopolysaccharidosis (MPS) Agents
Eltrombopag – rename Eltrombopag Derivatives, add Alvaiz to affected medications, update covered uses and age restriction
Ibrexafungerp – update required medical information and appropriate treatment
Immune Globulin – add Alyglo to affected medications
Maralixibat, Odevixibat – combine to Cholestatic Liver Disease
Mepolizumab – update required medical information
Miglustat – update required medical information and age restriction
Monomethyl Fumarate – update appropriate treatment
Myeloid Growth Factors – update covered uses
Non-Preferred Medical Drug Codes – update to include Pemrydi J9324
Opioid Quantity Above 90 Morphine Milligram Equivalents (MME) – update required medical information and coverage duration
Oteseconazole – update required medical information, exclusion criteria and age restriction
Ozanimod – update appropriate treatment
Siponimod – update appropriate treatment
Targeted Immune Modulators – update quantity limitations
Xeomin, Dysport, Myobloc, and Daxxify – update covered uses, appropriate treatment and coverage duration
Xifaxan – update covered uses and appropriate treatment

Preferred Drug List (PDL) Changes

July 2024. The following changes to the drug list are effective July 22, 2024:

Formulary Additions

Adalimumab-ryvk injection add Tier 3 with SP, quantity limit and medical necessity prior authorization
Alvaiz tablet add Tier 3 with SP, quantity limit and prior authorization
Alyglo add Tier 3 with SP, prior authorization
Dapagliflozin tablet add Tier 1 with quantity limit and medical necessity prior authorization
Dapagliflozin-metformin extended-release tablet add Tier 1 with quantity limit and medical necessity prior authorization
Mirabegron tablet add Tier 1 with quantity limit and step therapy
Rextovy nasal spray add Tier 2 with quantity over time limit
Rezdiffra tablet add Tier 3 with SP, quantity limit and prior authorization
RiVive nasal spray add Tier 2 with quantity over time limit
Simlandi injection add Tier 3 with SP, quantity limit and medical necessity prior authorization
Winrevair kit add Tier 3 with SP and prior authorization

Prior Authorization

Remove
- Teriflunomide tablet

Quantity Limit

Remove quantity limit
- Vancocin capsule
- Vancomycin capsule
Add quantity limit
- Praluent injection
Update quantity limit
- Kloxxado nasal spray
- Livmarli solution
- Naloxone nasal spray
- Narcan nasal spray

Removed from Formulary

Relyvrio packet

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

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