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November 2020 Drug List Change Notification

Updates on Existing Criteria:

November 2020. The following changes to criteria are effective November 22, 2020:

Preauthorization Criteria – Clinical Updates

  • Burosumab – update to include new indication
  • Ilaris – update criteria for indication of Still’s Disease
  • Remodulin – update required diagnostic information and exclusion criteria
  • Siltuximab – update required medical information and reauthorization criteria
  • Subcutaneous Immune Globulin – clarify covered conditions, criteria and dosing
  • Sublocade – update opioid dependence diagnostic criteria
  • Targeted Immune Modulators – add new indication for Cosentyx (non-radiographic axial spondyloarthritis)
  • Tyvaso – update required diagnostic information

Preauthorization Criteria – Clerical Updates

  • Dupilumab – add new formulation (pre-filled pen)
  • Naglazyme – rename galsulfase; reformat to provider attestation
  • Parathyroid Hormone Analogs – update name of Bonsity to Teriparatide
  • Parsabiv – rename Etelcalcetide
  • Relistor – rename Methylnaltrexone
  • Sinuva – rename Mometasone Sinus Implant

January 2021. The following changes to criteria are effective January 1, 2021:

Preauthorization Criteria – Clinical Updates

  • Antiemetics – remove Aloxi, Cinvanti, Emend from affected medications
  • Oncology Agents – add Liposomal Doxorubicin, Marqibo (liposomal vincristine), Vantas (histrelin acetate implant)

Preferred Drug List (PDL) Changes

November 2020. The following changes to the drug list are effective November 22, 2020:

Formulary Additions

  • Bafiertam Delayed Release capsule add Tier 3 with SP, quantity limit and preauthorization
  • Breztri Aerosphere add Tier 3 with medical necessity preauthorization
  • Convenience Pak add Tier 3 with medical necessity preauthorization
  • Dexabliss pack add Tier 3 with medical necessity preauthorization
  • Dimethyl Fumarate Delayed Release capsule add Tier 3 with SP, quantity limit and preauthorization
  • Helidac Therapy pack add Tier 3 with medical necessity preauthorization
  • Inqovi tablet add Tier 3 with SP, quantity limit and preauthorization
  • Kevzara auto injector add Tier 3 with SP and medical necessity preauthorization
  • Naloxone auto injector add Tier 1
  • Ortikos Extended Release capsule add Tier 3 with medical necessity preauthorization
  • Qutenza Kit add Tier 3 with medical necessity preauthorization
  • Teriparatide Pen injector add Tier 3 with SP and preauthorization
  • ZCORT 7day pack add Tier 3 with medical necessity preauthorization

Preauthorization Updates

  • Add medical necessity preauthorization:
    • Cephalexin tablet
    • Vectical ointment

Removed from Formulary

  • Aspirin 325mg tablet
  • Aspirin Delayed Release 325mg tablet

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

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

November 2020. The following changes to the drug list are effective November 22, 2020:

Formulary Additions

  • Bafiertam Delayed Release capsule add Tier 4 with SP, quantity limit and preauthorization
  • Cipro suspension add Tier 2
  • Dimethyl Fumarate Delayed Release capsule add Tier 3 with SP, quantity limit and preauthorization
  • Inqovi tablet add Tier 4 with SP, quantity limit and preauthorization
  • Naloxone auto injector add Tier 1
  • Teriparatide Pen injector add Tier 4 with SP and preauthorization

Removed from Formulary

  • Aspirin 325mg tablet
  • Aspirin Delayed Release 325mg tablet
  • Cephalexin tablet; consider cephalexin capsule or suspension
  • Guaifenesin-Codeine solution and syrup

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