Updates on Existing Criteria
October 2022. The following changes to criteria are effective October 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Addyi & Vyleesi – update covered uses, required medical information and prescriber restrictions
- Belimumab – remove dosing and update required medical information to include antibody testing for systemic lupus erythematosus (SLE)
- Dupilumab – update to include coverage for new indication of eosinophilic esophagitis
- Edaravone – update to include new Radicava ORS formulation and update riluzole requirement
- Erectile Dysfunction – move Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) definition to required medical information section and updated prescriber restriction
- Iloprost – Update required medical information
- Noxafil – update appropriate treatment regimen and other criteria
- Ocaliva – updated exclusion criteria
- Opioid Quantity Above 90 Morphine Milligram Equivalents (MME) – update conversion tablet to include tramadol and buprenorphine patches
- Oxybates – Updated required prior treatment for diagnosis of narcolepsy with cataplexy
- Ozurdex – update required medical information and define required zone of retinal thickening
- Saphnelo – updated required medical information to include antibody testing for systemic lupus erythematosus (SLE)
- Tasimelteon – Updated required medical information
- Tisagenlecleucel – update to include new indication of adult relapsed/refractory follicular lymphoma
- Zulresso – update covered uses
Preferred Drug List (PDL) Changes
October 2022. The following changes to the drug list are effective October 22, 2022:
Formulary Additions
- Depo-Testosterone add Tier 3 with prior authorization for ages 17 years and younger
- Entadfi capsule add Tier 3 with quantity limit and medical necessity prior authorization
- Fesoterodine fumarate extended release (ER) tablet add Tier 1 with quantity limit and step therapy
- Fosamprenavir tablet add Tier 1
- Methylphenidate patch add Tier 1 with quantity limit and prior authorization for ages 6 to 12 years (new starts only)
- Naproxen-esomeprazole DR tablet add Tier 1 with medical necessity prior authorization
- Olumiant tablet add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Paxlovid tablet add Tier 0 with quantity limit
- Radicava ORS suspension add Tier 3 with SP, limited access, quantity limit and prior authorization
- Testosterone cypionate solution add Tier 3 with prior authorization for ages 17 years and younger
- Tyvaso DPI kit add Tier 3 with SP, quantity limit and prior authorization
- Vivjoa capsule pack add Tier 3 with SP, limited access, quantity over time limit and prior authorization
- Vtama cream add Tier 3 with quantity limit and prior authorization
Prior Authorization Updates
- Add Medical Necessity
- Cyclosporine in Klarity ophthalmic emulsion
- Gleevec tablet
- Imbruvica tablet (140mg and 280mg only)
Quantity Limit Additions
- Advair Diskus
- Cyclosporine in Klarity ophthalmic emulsion
- Myrbetriq tablet
- Qbrexza pad
- Toviaz tablet
- Vascepa
Tier Update
- Lexiva
- Symbicort
- Vandazole gel
- Vascepa
Legacy Enhanced Drug List (LEDL) Updates (generic formulation for each remain on LEDL)
- Remove
- Advair Diskus
- Bystolic tablet
- ProAir HFA
- Symbicort
- Vascepa 1 gram capsule
- Ventolin HFA
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2022. The following changes to the drug list are effective October 22, 2022:
Formulary Additions
- Fesoterodine fumarate extended release (ER) tablet add Tier 1 with quantity limit and step therapy
- Fosamprenavir tablet add Tier 1
- Methylphenidate patch add Tier 1 with quantity limit and prior authorization for ages 6 to 12 years (new starts only)
- Naproxen-esomeprazole DR tablet add Tier 1 with medical necessity prior authorization
- Paxlovid tablet add Tier 0 with quantity limit
- Radicava ORS suspension add Tier 4 with SP, limited access, quantity limit and prior authorization
- Tyvaso DPI kit add Tier 4 with SP, quantity limit and prior authorization
- Vivjoa capsule pack add Tier 4 with SP, limited access, quantity over time limit and prior authorization
- Vtama cream add Tier 3 with quantity limit and prior authorization
Tier Update
- Vandazole gel
Prior Authorization Removal
- Icosapent ethyl capsule
- Vascepa 0.5 gram capsule
Quantity Limit Addition
- Myrbetriq tablet
Removed from Formulary
- Advair Diskus; consider fluticasone-salmeterol aerosol powder, wixela, budesonide-formoterol aerosol
- Daytrana patch; consider methylphenidate patch, amphetamine-dextroamphetamine extended release (ER) capsule, dextroamphetamine sulfate ER capsule, dexmethylphenidate ER capsule, methylphenidate ER (CD) capsule, methylphenidate ER (LA) capsule, methylphenidate ER tablet (non-osmotic formulation),
- Imbruvica 140mg and 280mg tablet; consider Imbruvica capsule
- Lexiva tablet; consider fosamprenavir tablet
- Symbicort; consider budesonide-formoterol aerosol, fluticasone-salmeterol aerosol powder, wixela
- Toviaz tablet; consider fesoterodine fumarate ER, oxybutynin, solifenacin, tolterodine, Trospium
- Upneeq ophthalmic solution
- Vascepa 1 gram capsule; consider icosapent ethyl capsule 1 gram
See the PacificSource Drug Lists page for the current drug list.