Updates on Existing Criteria:
March 2021. The following changes to criteria are effective March 22, 2021:
Preauthorization Criteria – Clinical Updates
- Arcalyst – Update to coverage for Deficiency of the IL-1 Receptor Antagonist (DIRA)
- Targeted Immune Modulators – Add Stelara as preferred medical drug
Preauthorization Criteria – Clerical Updates
- Radicava – update initial approval duration
Preferred Drug List (PDL) Changes
March 2021. The following changes to the drug list are effective March 22, 2021:
Formulary Additions
- Asenapine maleate sublingual tablet add Tier 1 with quantity limit and step therapy
- Eysuvis suspension add Tier 3
- FreeStyle Libre 2 Reader/Sensor add Tier 2 with quantity limit and preauthorization
- Humira pen add Tier 3 with SP, quantity limit and preauthorization
- LifEMS Naloxone prefilled syringe add Tier 3 with medical necessity preauthorization
- Nyvepria solution add Tier 3 with SP and preauthorization
- Sutab tablet add Tier 0 (ACA drug, limitations may apply)
- Winlevi cream add Tier 3 with medical necessity preauthorization
Quantity Limit Updates
- Add Quantity Limit
- Emflaza suspension
- Emflaza tablet
Step Therapy Updates
- Remove Step Therapy
- Actonel tablet
- Alendronate tablet
- Atelvia tablet
- Fosamax Plus D tablet
- Ibandronate tablet
- Risedronate tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
March 2021. The following changes to the drug list are effective March 22, 2021:
Formulary Additions
- Asenapine maleate sublingual tablet add Tier 1 with quantity limit and step therapy
- Emflaza oral suspension add Tier 4 with limited access, quantity limit and preauthorization
- Emflaza tablet add Tier 4 with limited access, quantity limit and preauthorization
- Eysuvis suspension add Tier 3
- FreeStyle Libre 2 Reader/Sensor add Tier 2 with quantity limit and preauthorization
- Humira pen add Tier 4 with SP, quantity limit and preauthorization
- Nyvepria solution add Tier 4 with SP and preauthorization
- Sutab tablet add Tier 0 (ACA drug, limitations may apply)
Step Therapy Updates
- Remove Step Therapy
- Alendronate tablet
- Ibandronate tablet
- Risedronate tablet
Removed from Formulary
- MoviPrep solution; consider PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-C solution
- Saphris sublingual tablet; consider aripiprazole tablet, olanzapine tablet, quetiapine tablet, risperidone tablet, ziprasidone tablet, asenapine maleate sublingual tablet
See the PacificSource Drug Lists page for the current drug list.