Updates on Existing Criteria:
October 2021. The following changes to criteria are effective October 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Addyi & Vyleesi – Update exclusion criteria
- Benralizumab - add Pulmonologist as allowed prescriber
- Dupilumab - add Pulmonologist as allowed prescriber
- Eculizumab – update required medical information and updated reauthorization criteria
- Histrelin - Update required medical information, provider restrictions and appropriate treatment for gender dysphoria
- Hormone Supplementation under 18 Years of Age - Update required medical information, provider restrictions and appropriate treatment for gender dysphoria
- Hydrocortisone Oral Granules – add reauthorization criteria
- Isavuconazonium Sulfate – Update required medical information for Mucormycosis
- Leuprolide- Update required medical information, provider restrictions and appropriate treatment for gender dysphoria
- Mepolizumab - add Pulmonologist as allowed prescriber
- Noxafil – update to include new indication of oropharyngeal candidiasis and required medical information
- Omalizumab – clarify definition of severe allergic asthma
- Reslizumab – add Pulmonologist as allowed prescriber
- Targeted Immune Modulators – remove CDAI requirement and add step through for severe ulcerative colitis
- Testopel - Update required medical information, provider restrictions and appropriate treatment for gender dysphoria
- Testosterone - Update required medical information, provider restrictions and appropriate treatment for gender dysphoria
- Trikafta – update pediatric dosing and age restriction
- Voriconazole – remove exclusion criteria
Preferred Drug List (PDL) Changes
October 2021. The following changes to the drug list are effective October 22, 2021:
Formulary Additions
- Ayvakit tablet add Tier 3 with SP, quantity limit and prior authorization
- Azstarys capsule add Tier 3 with quantity limit and medical necessity prior authorization
- Brexafemme tablet add Tier 3 with quantity over time limit and medical necessity prior authorization
- Etravirine tablet add Tier 1 with quantity limit
- Kloxxado nasal spray add Tier 2 with quantity over time limit
- Lopinavir-Ritonavir tablet add Tier 1 with quantity limit
- Lumakras tablet add Tier 3 with SP and prior authorization
- Myfembree tablet add Tier 3 with medical necessity prior authorization
- Myrbetriq oral granule suspension add Tier 3 with medical necessity prior authorization
- Rufinamide tablet add Tier 1 with prior authorization
- Trikafta Therapy Pack add Tier 3 with SP, limited access, quantity limit and prior authorization
- Truseltiq capsule pack add Tier 3 with SP, quantity limit and prior authorization
Tier Update
- Cefaclor ER tablet
Prior Authorization Updates
- Remove
- Osphena tablet
Quantity Limit Update
- Add
- Intelence tablet
- Kaletra tablet
- Osphena tablet
- Update to quantity over time
- Narcan nasal spray
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2021. The following changes to the drug list are effective October 22, 2021:
Formulary Additions
- Ayvakit tablet add Tier 4 with SP, quantity limit and prior authorization
- Etravirine tablet add Tier 1 with quantity limit
- Kloxxado nasal spray add Tier 2 with quantity over time limit
- Lopinavir-Ritonavir tablet add Tier 1 with quantity limit
- Lumakras tablet add Tier 4 with SP and prior authorization
- Rufinamide tablet add Tier 1 with prior authorization
- Testosterone 1.62% gel add Tier 1 with quantity limit and prior authorization
- Trikafta Therapy Pack add Tier 4 with SP, limited access, quantity limit and prior authorization
- Truseltiq capsule pack add Tier 4 with SP, quantity limit and prior authorization
Tier Updates
- Cefaclor ER tablet
- Rufinamide suspension
Quantity Limit Update
- Update to quantity over time limit
- Narcan nasal spray
Removed from Formulary
- Banzel tablet; consider rufinamide tablet
- Intelence tablet; consider etravirine tablet
- Kaletra tablet; consider lopinavir-ritonavir tablet
See the PacificSource Drug Lists page for the current drug list.