Updates on Existing Criteria
May 2023. The following changes to criteria are effective May 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Anti-Amyloid Monoclonal Antibody – add Leqembi
- Antiemetics – add melphalan to list of highly emetogenic chemotherapy agents
- Bevacizumab – update appropriate treatment and required medical information
- Caplacizumab-YHDP – update required medical information and coverage duration
- Continuous Glucose Monitors – add coverage criteria for non-preferred products
- Droxidopa – update covered uses
- Emsam – update age restriction
- Methylnaltrexone – update covered uses and reauthorization criteria
- Mitapivat – update required medical information
- Mometasone Sinus Implant – update to include repeat administration allowance
- Monomethyl Fumarate - update covered uses and required medical information, removed exclusion criteria
- Oncology Agents – add Jaypirca, Orserdu; remove Tukysa (add stand-alone)
- Orenitram – update required medical information
- Oxybates – update covered uses and clarify required medical information for each covered diagnosis
- Ozanimod - update covered uses and required medical information, removed exclusion criteria
- Rituximab – updated covered uses and corresponding required medical information for each covered use
- Solriamfetol – add amphetamine-dextroamphetamine to acceptable prior treatment
- Spinonimod - update covered uses and required medical information, removed exclusion criteria
- Spravato – update criteria for Treatment Resistant Depression coverage
- Teriflunomide – update covered uses and required medical information, removed exclusion criteria
- Tetrabenazine – remove stand-alone criteria and combine with Deutetrabenazine to create new VMAT2 Inhibitor policy
- Trikafta – update required medical information and update coverage duration
- Vumerity – renamed Diroximel Fumarate and updated covered uses and required medical information, removed exclusion criteria
Preferred Drug List (PDL) Changes
May 2023. The following changes to the drug list are effective May 22, 2023:
Formulary Additions
- Brimonidine tartrate gel add Tier 1 with step therapy
- Clonidine extended-release tablet add Tier 1 with quantity limit and medical necessity prior authorization
- Jaypirca tablet add Tier 3 with SP, partial fill, quantity limit and prior authorization
- Lurasidone tablet add Tier 1 with quantity limit and step therapy
- Minocycline extended-release tablet add Tier 1 with medical necessity prior authorization
- Nexiclon XR tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Orserdu tablet add Tier 3 with SP, partial fill, quantity limit and prior authorization
- Ozempic solution add Tier 2 with quantity limit and prior authorization
- Sodium oxybate solution add Tier 3 with SP, limited access, quantity limit and prior authorization
Tier Updates
- Latuda tablet
- NP Thyroid tablet
Prior Authorization
- Remove
- Fluocinonide cream 0.1%
- Add Medical Necessity
- Revatio oral suspension
- Revatio tablet
Removed from Formulary
- Atovaquone-Proguanil tablet
- Malarone tablet
- Mefloquine tablet
- Primaquine phosphate tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
May 2023. The following changes to the drug list are effective May 22, 2023:
Formulary Additions
- Brimonidine tartrate gel add Tier 1 with step therapy
- Fluocinonide cream add Tier 1
- Jaypirca tablet add Tier 4 with SP, partial fill, quantity limit and prior authorization
- Lurasidone tablet add Tier 1 with quantity limit and step therapy
- Orserdu tablet add Tier 4 with SP, partial fill, quantity limit and prior authorization
- Ozempic solution add Tier 2 with quantity limit and prior authorization
- Sodium Oxyate solution add Tier 4 with SP, limited access, quantity limit and prior authorization
Tier Update
- NP Thyroid tablet
Removed from Formulary
- Atovaquone-Proguanil tablet
- Latuda tablet; consider lurasidone tablet
- Mefloquine tablet
- Mirvaso gel; consider brimonidine tartrate gel
- Primaquine phosphate tablet
See the PacificSource Drug Lists page for the current drug list.