Updates on Existing Criteria
June 2023. The following changes to criteria are effective June 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Betaseron – update covered uses, required medical information, and increased covered duration
- Bevacizumab – update to include Vegzelma as non-preferred product
- Hereditary Angioedema – Remove current policy and replace with new formatting and preferred products for both acute and prophylaxis treatment
- Intravitreal Anti-VEGF Therapy – add new indication of Retinopathy of Prematurity (ROP)
- Obeticholic Acid – update covered uses and coverage duration
- Orkambi – update required medical information, coverage duration and uses
- Phesgo – update exclusion criteria
- Plegridy – updated covered uses, required medical information, and increased covered duration
- Sutimlimab – remove requirement for recent blood transfusions
- Symdeko – update required medical information, coverage duration and uses
- Symlin – rename Pramlintide and update covered uses and exclusion criteria
- Trastuzumab – update definition of HER2 positivity and added Herceptin Hylecta as non-preferred
Preferred Drug List (PDL) Changes
June 2023. The following changes to the drug list are effective June 22, 2023:
Formulary Additions
- Amjevita solution add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Amoxicillin-clarithromycin-lansoprazole pack add Tier 1
- Atorvaliq suspension add Tier 3 with medical necessity prior authorization
- Basaglar Tempo Pen add Tier 3 with medical necessity prior authorization
- Bismuth-metronidazole-tetracycline pack add Tier 1 with medical necessity prior authorization
- Dichlorphenamide tablet add Tier 1 with medical necessity prior authorization
- Diclofenac potassium packet add Tier 1 with quantity over time limit and medical necessity prior authorization
- Diltiazem extended release add Tier 1
- Firazyr prefilled syringe add Tier 3 with SP and medical necessity prior authorization
- Fluticasone-salmeterol aerosol inhaler add Tier 1 with quantity limit
- Isosorbide dinitrate-hydralazine tablet add Tier 1 with medical necessity prior authorization
- Konvomep add Tier 3 with medical necessity prior authorization
- Noxafil packet add Tier 3 with prior authorization
- Omeprazole delayed release capsule add Tier 1
- OneTouch delica lancing device add Tier 2
- Palonosetron solution add Tier 1
- Penciclovir cream add Tier 1 with step therapy
- Posaconazole oral suspension add Tier 1 with prior authorization
- Pradaxa packet add Tier 3 with medical necessity prior authorization
- Prevpac add Tier 3 with medical necessity prior authorization
- Rezvoglar KwikPen add Tier 3 with medical necessity prior authorization
- Sajazir prefilled syringe add Tier 1 with SP and prior authorization
- Skyclarys capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
- Takhzyro prefilled syringe add Tier 3 with SP and prior authorization
- Tasimelteon capsule add Tier 1 with SP, limited access, quantity limit and prior authorization
- Teriflunomide tablet add Tier 1 with SP, quantity limit and prior authorization
- Ursodiol capsule add Tier 3 with medical necessity prior authorization
- Vancomycin oral solution add Tier 2
Tier Update
- BiDil tablet
Quantity Limit
- Updates
- Buprenorphine-naloxone film
- Buprenorphine-naloxone sublingual tablet
- Dronabinol capsule
- Marinol capsule
- Suboxone film
Prior Authorization
- Add Medical Necessity
- Aubagio tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
June 2023. The following changes to the drug list are effective June 22, 2023:
Formulary Additions
- Amoxicillin-Clarithromycin-lansoprazole pack add Tier 1
- Bicillin LA suspension add Tier 3
- Cefepime solution add Tier 1
- Diclofenac potassium packet add Tier 1 with quantity over time limit and medical necessity prior authorization
- Estradiol gel add Tier 1 with prior authorization for ages 17 years and younger
- Fluticasone-salmeterol aerosol inhaler add Tier 1 with quantity limit
- Icatibant acetate solution add Tier 4 with SP and prior authorization
- Isosorbide dinitrate-hydralazine tablet add Tier 1 with medical necessity prior authorization
- Omeprazole delayed release capsule add Tier 1
- OneTouch Delica Lancing device add Tier 2
- Palonosetron solution add Tier 1
- Penciclovir cream add Tier 1 with step therapy
- Posaconazole oral suspension add Tier 1 with prior authorization
- Sajazir prefilled syringe add Tier 4 with SP and prior authorization
- Skyclarys capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
- Takhzyro prefilled syringe add Tier 4 with SP and prior authorization
- Tasimelteon capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
- Teriflunomide tablet add Tier 3 with SP, quantity limit and prior authorization
Quantity Limit Updates
- Austedo tablet
- Buprenorphine sublingual tablet
- Buprenorphine-naloxone film
- Buprenorphine-naloxone sublingual tablet
- Dronabinol capsule
Removed from Formulary
- Aubagio tablet; consider teriflunomide tablet
- BiDil tablet; consider isosorbide dinitrate tablet, hydralazine tablet
- Cambia packet; consider diclofenac potassium tablet, diclofenac sodium, ibuprofen, meloxicam, naproxen, nabumetone
- Denavir cream; consider acyclovir (tablet, capsule, solution, ointment), famciclovir tablet, valacyclovir tablet
- Divigel gel; consider estradiol gel
- Hetlioz capsule; consider tasimelteon capsule
- Noxafil suspension; consider Posaconazole oral suspension
See the PacificSource Drug Lists page for the current drug list.