Updates on Existing Criteria
March 2023. The following changes to criteria are effective March 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Actimmune – update covered uses and required medical information for all indications
- Alpha-1 Proteinase Inhibitors – update covered uses and required medical information
- Arcalyst – rename Rilonacept, define covered uses and update diagnostic requirements
- Avonex – update covered uses and required medical information for all indications
- Aztreonam – update required medical information and reauthorization criteria
- Copaxone – update covered uses
- Gilenya – add fingolimod 0.5mg capsule
- Ilaris - update required medical information and appropriate treatment regimen
- Isavuconazonium Sulfate – update required medical information
- Levoketoconazole – update covered uses
- Mecasermin – update covered uses, prescriber restriction and reauthorization criteria
- Medical Necessity – add Furoscix cartridge, Relexxii
- Myeloid Growth Factors – update covered uses to include new Udenyca indication
- Oncology Agents – add Lytgobi, Elahere
- Opzelura – Update covered uses and exclusion criteria
- Parathyroid Hormone – update required medical information and reauthorization criteria
- Prostaglandins Opthalmic Step Therapy – update step 2 to include new generic tafluprost PF 0.0015% (Zioptan will be step 2 drug for PDL only)
- Rebif - update covered uses and required medical information
- Romosozumab – update covered uses and diagnostic criteria for osteoporosis
- Sipuleucel-T – remove stand-alone policy and add to Oncology Agents criteria
- Trientine – update required medical information and reauthorization criteria
- Voxelotor – update reauthorization criteria
- Xgeva – update age restriction
Preferred Drug List (PDL) Changes
March 2023. The following changes to the drug list are effective March 22, 2023:
Formulary Additions
- Cimzia prefilled syringe add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Dexcom G7 system add Tier 2 with quantity limit and prior authorization
- Ermeza solution add Tier 3 with quantity limit
- Estradiol gel add Tier 1 with prior authorization for ages 17 years and younger
- Fabrazyme solution add Tier 3 with SP and prior authorization
- Fingolimod capsule add Tier 1 with SP, quantity limit and prior authorization
- Furoscix cartridge add Tier 3 with medical necessity prior authorization
- Ixinity solution add Tier 3 with SP and prior authorization
- Levothyroxine solution add Tier 3
- Lytgobi tablet pack add Tier 3 with SP, limited access, quantity limit and prior authorization
- Maraviroc tablet add Tier 1
- Mayzent tablet add Tier 3 with SP, quantity limit and prior authorization
- Menveo vaccine add Tier 0 (ACA limitations may apply)
- Oxbryta tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Relexxi extended release tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Tafluprost (PF) ophthalmic solution add Tier 1
Prior Authorization
- Remove
- Livalo tablet
- Vfend tablet
- Voriconazole tablet
- Add Medical Necessity
- Relexxi extended release tablet
- Vfend oral suspension
- Voriconazole oral suspension
Quantity Limit
- Add Quantity Limit
- Vfend oral suspension
- Vfend tablet
- Voriconazole oral suspension
- Voriconazole tablet
- Quantity Limit Update
- Livalo tablet
Tier Update
- Selzentry tablet
Remove from Formulary
- Clovique capsule
- Gilenya 0.25mg capsule
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
March 2023. The following changes to the drug list are effective March 22, 2023:
Formulary Additions
- Dexcom G7 system add Tier 2 with quantity limit and prior authorization
- Fingolimod capsule add Tier 4 with SP, quantity limit and prior authorization
- Lytgobi tablet pack add Tier 4 with SP, limited access, quantity limit and prior authorization
- Maraviroc tablet add Tier 1
- Menveo solution add Tier 0 (ACA limitations may apply)
- Oxbryta tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Tafluprost ophthalmic solution add Tier 1 with step therapy
Quantity Limit
- Add Quantity Limit
- Voriconazole oral suspension
- Voriconazole tablet
- Quantity Limit Update
- Livalo tablet
Prior Authorization
- Remove
- Livalo tablet
- Voriconazole tablet
- Add Medical Necessity
- Voriconazole oral suspension
Removed from Formulary
- Clovique capsule
- Esbriet capsule; consider pirfenidone tablet
- Gilenya 0.25mg capsule
- Selzentry tablet; consider maraviroc tablet
- Zioptan ophthalmic solution; consider latanoprost solution, bimatoprost solution, tafluprost ophthalmic solution
See the PacificSource Drug Lists page for the current drug list.