March Drug List Change Notification

January 19, 2022

Updates on Existing Criteria

March 2022. The following changes to criteria are effective March 22, 2022:

Prior Authorization Criteria – Clinical Updates

Adenosine Deaminase (ADA) Replacement – update prescriber restrictions and dose rounding
Arcalyst – update required medical information and pediatric dosing
Bevacizumab – update to include new indication of stage III and stage IV epithelial ovarian, fallopian tube or primary peritoneal cancer following initial surgical resection
Strensiq – update required medical information, appropriate dosing and reauthorization criteria
Vaginal Progesterone – Update appropriate treatment regimen and duration of coverage

Prior Authorization Criteria – Clerical Updates

Carbaglu – rename Carglumic Acid
Radicava – rename Edaravone

Preferred Drug List (PDL) Changes

March 2022. The following changes to the drug list are effective March 22, 2022:

Formulary Additions

Adapalene-benzoyl peroxide gel add Tier 1
Besremi add Tier 3 with SP, limited access, quantity limit and prior authorization
Carglumic acid tablet add Tier 1 with SP and prior authorization
Cataflam tablet add Tier 1 with medical necessity prior authorization
Chlorpromazine oral concentrate add Tier 3
Dexlansoprazole delayed release capsule add Tier 1 with quantity limit and medical necessity prior authorization
Dextroamphetamine tablet add Tier 1 with quantity limit and prior authorization
Diclofenac potassium tablet add Tier 1 with medical necessity prior authorization
Difluprednate ophthalmic emulsion add Tier 1
Elyxyb solution add Tier 3 with medical necessity prior authorization
Enalapril oral solution add Tier 1 with medical necessity prior authorization
Epclusa packet add Tier 3 with SP, quantity limit and medical necessity prior authorization
Everolimus tablet add Tier 1 with SP, quantity limit and prior authorization
FC2 Female condom add Tier 0 with quantity over time limit (ACA drug, limitations may apply)
Fenofibrate capsule add Tier 1
Fenofibrate tablet add Tier 1
Ibuprofen-famotidine tablet add Tier 1 with quantity limit and medical necessity prior authorization
Ingrezza capsule add Tier 3 with medical necessity prior authorization
Levothyroxine solution add Tier 3
Livtencity tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
Lofena tablet add Tier 1 with medical necessity prior authorization
Mavyret packet add Tier 3 with SP, quantity limit and medical necessity prior authorization
Nitroglycerin sublingual tablets add Tier 1
Pancreaze capsule add Tier 3
Potassium chloride extended release tablet add Tier 1
Sunitinib capsule add Tier 1 with SP, limited access, quantity limit and prior authorization
Thalitone tablet add Tier 3 with medical necessity prior authorization
Tirosint-SOL solution add Tier 3
Voxzogo solution add Tier 3 with SP, quantity limit and prior authorization
Vuity solution add Tier 3 with quantity limit and medical necessity prior authorization
Xarelto suspension add Tier 2
Xofluza therapy pack add Tier 3 with quantity over time limit

Prior Authorization Update

Update Prior Authorization (add Medical Necessity)
- Glatiramer solution
- Glatopa solution
Remove Prior Authorization
- Vivitrol suspension

Step Therapy Updates

Remove Step Therapy
- Lokelma packet
Update Step Therapy
- Quetiapine fumarate extended release tablet
- Seroquel XR tablet

Quantity Limit Updates

Add Quantity Limit
- Eliquis tablet
- Lokelma packet
- Vivitrol suspension
- Xarelto tablet
Remove Quantity Limit
- Crestor tablet
- Rosuvastatin tablet

Tier Updates

Sutent capsule

Removed from Formulary

Hydromorphone suppository
Morphine sulfate suppository

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes