Updates on Existing Criteria:
October 2020. The following changes to criteria are effective October 22, 2020:
Preauthorization Criteria – Clinical Updates
- Dupilumab – update age restriction and dosing
- Histrelin – clarify baseline estradiol and testosterone levels required for tanner stage 2 or below
- Leuprolide – clarify baseline estradiol and testosterone levels required for tanner stage 2 or below
- Ocrelizumab – rename Ocrelizumab and clarify rituximab biosimilar requirement for relapsing remitting multiple sclerosis (RRMS)
- Perjeta – remove stand-alone criteria and add to General Oncology Agent criteria
- Probuphine – update required medical information including stability on oral buprenorphine
- Radicava – update to require trial with riluzole
- Soliris – update to include step through Uplizna for Neuromyelitis Optica Spectrum Disorder (NMOSD)
- Testopel – clarify baseline estradiol and testosterone levels required for tanner stage 2 or below
- Testosterone – clarify baseline estradiol and testosterone levels required for tanner stage 2 or below
- Vfend – rename Voriconazole and update age restriction
Preauthorization Criteria – Clerical Updates
- Evenity – rename Romosozumab
- Evomela – rename Melphalan
- Gattex – rename Teduglutide rDNA
- Increlix – rename Mecasermin
- Lemtrada – rename Alemtuzumab
- Mepsevii – rename Vestronidase alpha
- Natpara – rename Parathyroid Hormone
- Nplate – rename Romiplostim
- Pulmozyme – rename Dornase alfa
Preferred Drug List (PDL) Changes
October 2020. The following changes to the drug list are effective October 22, 2020:
Formulary Additions
- Convenience Pack add Tier 3 with medical necessity preauthorization
- Dojolvi liquid add Tier 3 with SP and preauthorization
- Fintepla solution add Tier 3 with SP, quantity limit and preauthorization
- Gabapal Therapy Pack add Tier 3 with medical necessity preauthorization
- GPL Pack add Tier 3 with medical necessity preauthorization
- Lidotin Therapy Pack add Tier 3 with medical necessity preauthorization
- Lyumjev solution (Vial and Kwikpen) add Tier 3 with medical necessity preauthorization
- Mycapssa add Tier 3 with medical necessity preauthorization
- NOpioid-TC kit add Tier 3 with medical necessity preauthorization
- Pentican Therapy Pack add Tier 3 with medical necessity preauthorization
- Rukobia add Tier 3 with quantity limit
- Tasoprol kit add Tier 3 with medical necessity preauthorization
- Tivicay PD soluble tablet add Tier 3 with quantity limit
- Twirla patch add Tier 0 (ACA drug, limits may apply)
- Xpovio Therapy Pack add Tier 3 with limited access, quantity limit and preauthorization
- Zolpak kit add Tier 3 with medical necessity preauthorization
Step Therapy Update
- Avodart capsule
- Dutasteride capsule
Quantity Limit Update
- Update quantity limit:
- Xpovio tablet therapy pack
Preauthorization Updates
- Add preauthorization:
- Sivextro tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2020. The following changes to the drug list are effective October 22, 2020:
Formulary Additions
- Butorphanol nasal spray add Tier 1 with quantity limit
- Ciprofloxacin Otic solution 0.2% add Tier 1
- Dojolvi liquid add Tier 4 with SP and preauthorization
- Fintepla solution add Tier 4 with SP and preauthorization
- Rukobia tablet add Tier 3 with quantity limit
- Tivicay PD soluble tablet add Tier 2 with quantity limit
- Twirla patch add Tier 0 (ACA drug, limits may apply)
- Xpovio tablet therapy pack add Tier 4 with limited access, quantity limit and preauthorization
Preauthorization Updates
- Add preauthorization:
- Sivextro tablet
Removed from Formulary
- Axert tablet; consider eletriptan, naratriptan, sumatriptan, rizatriptan, zolmitriptan, almotriptan
See the PacificSource Drug Lists page for the current drug list.