Updates on Existing Criteria
March 2025. The following changes to criteria are effective March 22, 2025:
Prior Authorization Criteria – Clinical Updates
- Calcitonin Gene-Related Peptide (CGRP) Inhibitors – remove Nurtec tablet from affected medications and update appropriate treatment
- Medical Necessity – add Nurtec tablet, Sprycel tablet, and tazarotene cream 0.05% to affected medications
Preferred Drug List (PDL) Changes
March 2025. The following changes to the drug list are effective March 22, 2025:
Formulary Additions
- Tazarotene cream 0.05% add tier 1 with medical necessity prior authorization
Prior Authorization
- Add Medical Necessity
- Nurtec tablet
Sprycel tablet
Removed from Formulary
- Nymyo tablet
- Tri-Nymyo tablet
Quantity Limit
- Update
- Firdapse tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
March 2025. The following changes to the drug list are effective March 22, 2025:
Removed from Formulary
- Nurtec tablet; consider almotriptan tablet, eletriptan tablet, naratriptan tablet, sumatriptan (tablet, solution, and injection), rizatriptan tablet, zolmitriptan (tablet and solution), frovatriptan tablet, Reyvow tablet
- Nymyo tablet
- Sprycel tablet; consider dasatinib tablet
- Tri-Nymyo tablet
Quantity Limit
- Update
- Firdapse tablet
See the PacificSource Drug Lists page for the current drug list.