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November 2023 Drug List Change Notification (Commercial)

Updates on Existing Criteria

November 2023. The following changes to criteria are effective November 22, 2023:

Prior Authorization Criteria – Clinical Updates

  • Adenosine Deaminase (ADA) Replacement – update covered uses, required medical information and reauthorization requirement
  • Anifrolumab – update exclusion criteria (clerical changes)
  • Belimumab – update required medical information and appropriate treatment regimen
  • Cerliponase – update covered uses, exclusion criteria and required medical information
  • Dasatinib – update appropriate treatment regimen
  • Etranacogene – update required medical information, exclusion criteria and appropriate treatment regimen
  • Gonadotropin – update covered uses and appropriate treatment regimen
  • Goserelin Acetate Implant – update covered uses and clarify coverage for endometriosis and endometrial thinning
  • Histrelin – Update coverage for gender dysphoria
  • Immune Globulin – update initial approval criteria and dosing
  • Inclisiran – add criteria for new indication of primary hyperlipidemia
  • Leuprolide – update covered uses, required medical information and appropriate treatment regimen
  • Nafarelin – update covered uses and requirement for endometriosis
  • Nilotinib – update appropriate treatment regimen
  • Odevixibat – add criteria for new indication of Cholestatic pruritus in patients with Alagille syndrome (ALGS)
  • Qutenza – rename Capsaicin Kit and update covered uses and appropriate treatment regimen
  • Relyvio – update age restriction
  • Stimulants – update covered uses and remove age restriction
  • Targeted Immune Modulators – add Hadlima to mirror current Humira placement as preferred product
  • Thalidomide – update appropriate treatment regimen
  • Xiaflex – update required medical information and appropriate treatment regimen

Step Therapy Criteria – Clinical Updates

  • Atypical Antipsychotics – update paliperidone extended-release tablet to step 1 and remove Invega extended release tablet

 

Preferred Drug List (PDL) Changes

November 2023. The following changes to the drug list are effective November 22, 2023:

Formulary Additions

  • Adalimumab-adaz kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Adalimumab-fkjp kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Arexvy injection add Tier 0
  • Arysvo injection add Tier 0
  • Austedo titration pack add Tier 3 with SP, quantity limit and prior authorization
  • Brenzavvy tablet add Tier 3 with medical necessity prior authorization
  • Breyna inhaler add Tier 1 with quantity limit
  • Brixadi (monthly) prefilled syringe add Tier 3 with SP, limited access and quantity limit
  • Brixadi (weekly) prefilled syringe add Tier 3 with SP, limited access and quantity limit
  • Cosentyx UnoReady injector add Tier 3 with SP and prior authorization
  • Darunavir tablet add Tier 1
  • Hadlima syringe add Tier 3 with SP, quantity limit and prior authorization
  • Hulio kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Hyrimoz kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Idacio kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Joyeaux tablet add Tier 0 (ACA drug, limitations may apply)
  • Levonorgestrel-Ethinyl Estradiol-FE tablet add Tier 0 (ACA drug, limitations may apply)
  • Lisdexamfetamine capsule add Tier 1 with quantity limit and prior authorization for new starts only (ages 6 to 12 years)
  • Lisdexamfetamine chewable tablet add Tier 1 with quantity limit and prior authorization for new starts only (ages 6 to 12 years)
  • Olpruva pack add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Saxagliptin tablet add Tier 1 with medical necessity prior authorization
  • Saxagliptin-metformin extended-release tablet add Tier 1 with medical necessity prior authorization
  • Talzenna capsule add Tier 3 with SP, partial fill, quantity limit and prior authorization
  • Tiotropium bromide monohydrate capsule for inhalation add Tier 1 with quantity limit
  • Varenicline starter pack add Tier 0 (ACA drug, limitations may apply) with quantity over time limit
  • Yuflyma kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
  • Yusimry pen injector add Tier 3 with SP, quantity limit and medical necessity prior authorization

Quantity Limit

  • Add quantity limit
    • Amjevita prefilled syringe
    • Sublocade prefilled syringe

Prior Authorization

  • Add medical necessity
    • Buphenyl powder
    • Buphenyl tablet
    • Invega extended-release tablet
  • Remove prior authorization
    • Sublocade prefilled syringe

Step Therapy

  • Step Therapy removal
    • Invega extended-release tablet
  • Step Therapy update
    • Paliperidone extended-release tablet

Tier Update

  • Nevirapine oral suspension
  • Prezista tablet (600mg and 800mg only)
  • Spiriva Handihaler
  • Vyvanse capsule
  • Vyvanse chewable tablet

Legacy Enhanced Drug List Removals

  • Spiriva Handihaler

Exclusions

  • Litfulo (due to approval for cosmetic use only)

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

 

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

November 2023. The following changes to the drug list are effective November 22, 2023:

Formulary Additions

  • Arexvy injection add Tier 0
  • Arysvo injection add Tier 0
  • Austedo titration pack add Tier 4 with SP, quantity limit and prior authorization
  • Breyna inhaler add Tier 1 with quantity limit
  • Brixadi (monthly) prefilled syringe add Tier 4 with SP, limited access and quantity limit
  • Brixadi (weekly) prefilled syringe add Tier 4 with SP, limited access and quantity limit
  • Cosentyx UnoReady injector add Tier 4 with SP and prior authorization
  • Darunavir tablet add Tier 1
  • Hadlima syringe add Tier 4 with SP, quantity limit and prior authorization
  • Joyeaux tablet add Tier 0 (ACA drug, limitations may apply)
  • Levonorgestrel-Ethinyl Estradiol-FE tablet add Tier 0 (ACA drug, limitations may apply)
  • Lisdexamfetamine capsule add Tier 1 with quantity limit and prior authorization for new starts only (ages 6 to 12 years)
  • Lisdexamfetamine chewable tablet add Tier 1 with quantity limit and prior authorization for new starts only (ages 6 to 12 years)
  • Nevirapine oral suspension add Tier 1
  • Sublocade add Tier 4 with SP, limited access and quantity limit
  • Talzenna capsule add Tier 4 with SP, partial fill, quantity limit and prior authorization
  • Tiotropium bromide monohydrate capsule for inhalation add Tier 1 with quantity limit
  • Varenicline starter pack add Tier 0 (ACA drug, limitations may apply) with quantity over time limit

Step Therapy Update

  • Paliperidone extended-release tablet

Removed from Formulary

  • Balcoltra tablet; consider levonorgestrel-ethinyl estradiol-FE tablet, Joyeaux tablet
  • Prezista (600mg and 800mg) tablet; consider darunavir tablet
  • Spiriva Handihaler; consider tiotropium bromide monohydrate capsule for inhalation
  • Vyvanse capsule; consider lisdexamfetamine capsule, amphetamine-dextroamphetamine extended release (ER) capsule, dextroamphetamine sulfate ER capsule, dexmethylphenidate ER capsule, methylphenidate ER (CD) capsule, methylphenidate ER (LA) capsule, methylphenidate ER tablet (18mg, 27mg, 36mg, 54 mg)
  • Vyvanse chewable tablet; consider lisdexamfetamine chewable tablet, amphetamine-dextroamphetamine extended release (ER) capsule, dextroamphetamine sulfate ER capsule, dexmethylphenidate ER capsule, methylphenidate ER (CD) capsule, methylphenidate ER (LA) capsule, methylphenidate ER tablet (18mg, 27mg, 36mg, 54 mg)

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

 

Individual & Family, and Employer Providers