July 2022 Drug List Change Notification

May 20, 2022

Updates on Existing Criteria

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

Prior Authorization Criteria – Clinical Updates

Carglumic acid – update required medical information and appropriate treatment regimen for each covered indication
Empaveli – rename Pegcetacoplan and update reauthorization criteria
Etelcalcetide – update reauthorization criteria
Evkeeza and Juxtapid – clarify covered uses
Fenfluramine – update to include new indication (Lennox-Gastaut Syndrome) and appropriate treatment regimen
Hormone Supplementation Under 18 Years of Age – update to include transdermal testosterone
Leuprolide – add Camcevi to affected medications
Oncology Agents – add Opdualag, Pluvicto, Opdivo and Vonjo to affected medications
Opdivo – remove stand-alone policy and add to Oncology Agents criteria
Targeted Immune Modulators – move Avsola to non-preferred products for all covered indications
Testosterone – rename “Oral Testosterone”, remove topical testosterone products from criteria and add new drug Tlando

Step Therapy Criteria – Clinical Updates

Prior Authorization Criteria – Clerical Updates

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

Formulary Additions

Betaine powder add Tier 1 with SP, limited access and prior authorization
Camcevi prefilled syringe add Tier 3 with SP and prior authorization
Crinone gel add Tier 3 with medical necessity prior authorization
Diclofenac potassium capsule add Tier 1 with medical necessity prior authorization
Lacosamide tablet and solution add Tier 1
Omnipod 5 G6 pod/intro kit add Tier 2 with quantity limit
Ozempic solution add Tier 2 with quantity limit and prior authorization
Quviviq tablet add Tier 3 with quantity limi
Tlando capsule add Tier 3 with quantity limit and prior authorization
Triumeq PD soluble tablet add Tier 2 with quantity limit
Vijoice tablet pak add Tier 3 with SP, quantity limit and prior authorization
Vonjo capsule add Tier 3 with SP, limited access, quantity limit and prior authorization

Prior Authorization Update

Add Prior Authorization (Medical Necessity)
- Crinone vaginal gel
- Dxevo 11 day pack
Remove Prior Authorization
- Androderm patch
- Axiron solution
- Capecitabine tablet
- Testim gel
- Testosterone topical gel/solution

Step Therapy Updates

Quantity Limit Updates

Tier Update

Removed from Formulary

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