Updates on Existing Criteria:
November 2021. The following changes to criteria are effective November 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Alemtuzumab – update required medical information and prescriber restrictions
- Botox – update prescriber restrictions
- Enfortumab – remove stand alone and add Padcev to General Oncology prior authorization criteria
- Intravitreal Anti-VEGF Therapy – Add Myopic Choroidal Neovascularization (mCNV) indication for Lucentis
- Mepolizumab – add criteria for new indication of Chronic Rhinosinusitis with nasal polyps (CRSwNP)
- Opioid Quantity Above 120 Morphine Milligram Equivalents (MME) – update to 110 MME limit
- Ravulizumab – update required medical information, age restriction and weight based dosing
- Prior Authorization Criteria – Clerical Updates
- Austedo – rename Dalfampridine
- Mayzent – rename Siponimod
Preferred Drug List (PDL) Changes
November 2021. The following changes to the drug list are effective November 22, 2021:
Formulary Additions
- Antivert tablet add Tier 3
- Arformoterol solution add Tier 1 with quantity limit
- Bepotastine ophthalmic solution add Tier 1
- Bylvay capsule add Tier 3 with SP, limited access and prior authorization
- Clemastine syrup add Tier 3 with medical necessity prior authorization
- Formoterol solution add Tier 1 with quantity limit
- Humatin capsule add Tier 3 with medical necessity prior authorization
- Kerendia tablet with SP, limited access, quantity limit and medical necessity prior authorization
- Mayzent starter pack add Tier 3 with SP and prior authorization
- Mestinon solution add Tier 3
- Nalocet tablet add Tier 3 with medical necessity prior authorization
- Oxycodone-acetaminophen tablet Tier 3 with medical necessity prior authorization
- Pradaxa capsule add Tier 3 with medical necessity prior authorization
- Pyridostigmine ER tablet add Tier 1
- Rezurock tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Tazarotene foam add Tier 1 with medical necessity prior authorization
- Tiopronin tablet add Tier 3 with medical necessity prior authorization
- Xcopri tablet add Tier 3 with SP, limited access, quantity limit and medical necessity prior authorization
Tier Update
- Hydrocodone bitartrate ER 12 hour tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
November 2021. The following changes to the drug list are effective November 22, 2021:
Formulary Additions
- Arformoterol solution add Tier 1 with quantity limit
- Aurovela FE 1/20 add Tier 0 (ACA limitations may apply)
- Bepotastine ophthalmic solution add Tier 1
- Blisovi FE 1/20 add Tier 0 (ACA limitations may apply)
- Bylvay capsule add Tier 4 with SP, limited access and prior authorization
- Formoterol solution add Tier 1 with quantity limit
- Hailey FE 1/20 add Tier 0 (ACA limitations may apply)
- Kineret prefilled syringe add Tier 4 with SP, quantity limit and medical necessity prior authorization
- Larin FE 1/20 tablet add Tier 0 (ACA limitations may apply)
- Loestrin FE 1/20 tablet add Tier 0 (ACA limitations may apply)
- Mayzent starter pack add Tier 4 with SP and prior authorization
- Norethindrone Ace-Eth Estradiol FE tablet add Tier 0 (ACA limitations may apply)
- Pyridostigmine bromide ER tablet add Tier 1
- Rezurock tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Tazarotene foam add Tier 1 with medical necessity prior authorization
Tier Updates
- Hydrocodone bitartrate ER 12 hour capsule
Removed from Formulary
- Bepreve solution; consider bepotastine solution
- Brovana solution; consider arformoterol solution
- Fabior foam; consider tretinoin (gel, cream), adapalene (gel, cream), tazarotene cream
- Mestinon ER tablet tablet; consider pydridostigmine ER tablet
- Mestinon Syrup; consider pydridostigmine syrup
- Perforomist; consider formoterol solution
See the PacificSource Drug Lists page for the current drug list.