Updates on Existing Criteria:
June 2021. The following changes to criteria are effective June 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Botox – Update appropriate treatment for bladder conditions
- Muscular Dystrophy RNA Therapy – Add Amondys 45 to affected medications
- Oncology Agents – adding Cosela, Margenza, Pepaxto to affected medications
Preferred Drug List (PDL) Changes
June 2021. The following changes to the drug list are effective June 22, 2021:
Formulary Additions
- BD insulin syringe add Tier 2
- Bronchitol capsule add Tier 3 with SP, quantity limit and prior authorization
- Hydrocodone ER 12 hour capsule add Tier 1 with step therapy
- Hydromorphone ER 24 hour tablet add Tier 1 with step therapy
- Nymyo tablet add Tier 0 (ACA limitations may apply)
- Progesterone capsule add Tier 1
- Tri-Nymyo tablet add Tier 0 (ACA limitations may apply)
- Tyblume chewable tablet add Tier 0 (ACA limitations may apply)
- Zohydro ER 12 hour capsule add Tier 3 with step therapy
- Zolmitriptan nasal spray add Tier 1 with quantity over time limit and step therapy
Quantity Limit Updates
-
- Add Quantity Limit
- Biktarvy tablet
- Gocovri capsule
- Add Quantity Limit
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
June 2021. The following changes to the drug list are effective June 22, 2021:
Formulary Additions
- Alvesco inhaler add Tier 3 with quantity limit and medical necessity prior authorization
- Ascorbic Acid injection add Tier 1
- Bronchitol capsule add Tier 4 with SP, quantity limit and prior authorization
- Carisoprodol-Aspirin-Codeine tablet add Tier 1 with medical necessity prior authorization
- Chlordiazepoxide-Amitriptyline tablet add Tier 1
- Duavee tablet add Tier 3
- Helidac Pack add Tier 3 with medical necessity prior authorization
- Hydrocodone ER 12 hour capsule add Tier 1 with step therapy
- Hydromorphone ER 24 hour tablet add Tier 1 with step therapy
- Naproxen-Esomeprazole DR tablet add Tier 1 with medical necessity prior authorization
- Neupro patch add Tier 3
- Nymyo tablet add Tier 0 (ACA limitations may apply)
- Orphenadrine-Aspirin-Caffeine tablet add Tier 1 with medical necessity prior authorization
- Perphenazine-Amitriptyline tablet add Tier 1
- Pred-G ointment add Tier 3
- Pred-G suspension add Tier 3
- Progesterone capsule add Tier 1
- Sumatriptan-naproxen tablet add Tier 1 with quantity over time limit and medical necessity prior authorization
- Trintellix tablet add Tier 3 with quantity limit and step therapy
- Tri-Nymyo tablet add Tier 0 (ACA limitations may apply)
- Tuxarin ER tablet add Tier 3 with quanity limit
- Zolmitriptan nasal spray add Tier 1 with quantity over time limit and step therapy
- Zylet suspension add Tier 3
Quantity Limit Updates
- Add Quantity Limit
- Biktarvy tablet
Tier Update
- Vivitrol injection
Removed from Formulary
- Zomig Nasal Spray; consider sumatriptan (oral tablet, nasal spray, injection), zolmitriptan nasal spray
See the PacificSource Drug Lists page for the current drug list.