Updates on Existing Criteria
November 2024. The following changes to criteria are effective November 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Afinitor – update appropriate treatment and coverage duration
- Anti-Amyloid Monoclonal Antibody – add Kisunla and remove Aduhelm
- Asciminib – update required medical information, appropriate treatment, and exclusion criteria
- Besremi – add new policy and remove Besremi from Oncology Agents policy
- Betaine – update required medical information and appropriate treatment
- Blinatumomab – remove policy and add to Oncology Agents policy
- Danicopan – update exclusion criteria
- Delandistrogene Moxeparvovec-rokl – update covered uses, exclusion criteria and age restriction
- Ergot Alkaloids – update required medical information and appropriate treatment
- Hyftor – update required medical information, appropriate treatment, and exclusion criteria
- Levoketoconazole – update required medical information and appropriate treatment
- Medical Necessity – add clobetasol propionate ophthalmic suspension, Acthar gel, Ohtuvayre suspension, Sofdra gel, Faslodex solution
- Miltefosine – update covered uses, required medical information, and exclusion criteria
- Oral-Intranasal Fentanyl – update covered uses, required medical information, and appropriate treatment
- Osilodrostat – update required medical information and appropriate treatment
- Phenoxybenzamine – update required medical information and appropriate treatment
- Signifor – update required medical information, appropriate treatment, and exclusion criteria
- Signifor LAR – replace existing policy with new policy
- Somavert – replace existing policy with new policy
- Tagraxofusp-erzs – update required medical information, and age restriction
- Targeted Immune Modulators – update age restriction for Otezla for indication of plaque psoriasis
- Tedizolid – update appropriate treatment
- Topical Dermatitis and Psoriatic Agents – update policy name from Topical Antipsoriatics and add Zoryve 0.15 percent cream for new indication of atopic dermatitis
- Tralokinumab – add Adbry 300 mg/2 mL autoinjectors
- Voclosporin – update coverage duration
- Xeomin, Dysport, Myobloc, and Daxxify – update exclusion criteria
- Xuriden – update required medical information and appropriate treatment
Preferred Drug List (PDL) Changes
November 2024. The following changes to the drug list are effective November 22, 2024:
Formulary Additions
- Acthar Gel auto-injector add Tier 3 with medically necessity prior authorization
- Adbry auto-injector add Tier 3 with SP, quantity limit and prior authorization
- Austedo XR extended release tablet (18 mg) add Tier 3 with SP, quantity limit and prior authorization
- Clobetasol Propionate ophthalmic suspension add Tier 3 with medical necessity prior authorization
- Fulvestrant solution add Tier 3
- Livmarli 19 mg/mL solution add Tier 3 with SP, quantity limit and prior authorization
- Ohtuvayre suspension add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Otezla 20 mg tablet add Tier 3 with SP, quantity limit and prior authorization
- Retevmo tablet add Tier 3 with SP, quantity limit and prior authorization
- Scemblix tablet add Tier 3 with SP, quantity limit and prior authorization
- Sofdra gel add Tier 3 with quantity limit and medical necessity prior authorization
- Zoryve 0.15 percent cream add Tier 3 with quantity limit and prior authorization
Prior Authorization
- Add Medical Necessity
- Acthar Gel auto-injector
- Clobetasol Propionate ophthalmic suspension
- Faslodex solution
- Ohtuvayre suspension
- Sofdra gel
Quantity Limit
- Update
- Austedo XR extended release
- Livmarli solution
- Retevmo capsule
Removed from Formulary
- Aggrenox capsule
- Digitek tablet
- Lastacaft solution; consider azelastine, bepotastine, cromolyn, emidine, epinastine, alocril, alomide
- Macrilen packet
- Nadolol-Bendroflumethiazide tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
November 2024. The following changes to the drug list are effective November 22, 2024:
Formulary Additions
- Adbry auto-injector add Tier 4 with SP, quantity limit and prior authorization
- Austedo XR extended release tablet (18 mg) add Tier 4 with SP, quantity limit and prior authorization
- Fulvestrant solution add Tier 3
- Livmarli 19 mg/mL solution add Tier 4 with SP, quantity limit and prior authorization
- Otezla 20 mg tablet add Tier 4 with SP, quantity limit and prior authorization
- Retevmo tablet add Tier 4 with SP, quantity limit and prior authorization
- Scemblix tablet add Tier 4 with SP, quantity limit and prior authorization
- Zoryve 0.15 percent cream add Tier 3 with quantity limit and prior authorization
Quantity Limit
- Update
- Austedo XR extended release
- Livmarli solution
- Retevmo capsule
Removed from Formulary
- Aggrenox capsule
- Faslodex solution; consider fulvestrant solution
- Lastacaft solution; consider azelastine, bepotastine, cromolyn, emidine, epinastine, alocril, alomide
- Macrilen packet
- Nadolol-Bendroflumethiazide tablet
See the PacificSource Drug Lists page for the current drug list.