Updates on Existing Criteria
October 2023. The following changes to criteria are effective October 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Actiq – remove stand-alone policy and add product to “Fentanyl (Oral-Intranasal)” policy
- Amvuttra – update required medical information and reauthorization criteria
- Apomorphine – update exclusion criteria
- Asciminib – update appropriate treatment regimen
- Fentanyl (Oral-Intranasal) – rename “Oral-Intranasal Fentanyl” and update covered uses, exclusion criteria and appropriate treatment regimen
- Oncology Agents – update to include Columvi, Zejula tablets, Tivdak, Piqray
- Onpattro – rename “Patisiran” and update appropriate treatment regimen and baseline required information
- Parathyroid Hormone Analogs – update covered uses and required medical information
- Piqray – remove stand-alone policy
- Ravicti – update appropriate treatment and reauthorization criteria
- Sodium Phenylbutyrate – Update covered uses and appropriate treatment regimen
- Tafamidis – update reauthorization criteria and exclusion criteria
- Tegsedi – rename “Inotersen” and update reauthorization criteria and exclusion criteria
- Tivdak – remove stand-alone policy
- Tobramycin inhalation – remove age restriction and exclusion criteria
- Tolvaptan – remove dosing and update exclusion criteria
- Vyvgart – remove stand-alone policy and create new “Neonatal FC Receptor Antagonists” policy to include new Vyvgart Hytrulo and Rystiggo products
- Yonsa – update age restriction and required medical information
- Zejula – remove stand-alone policy
Preferred Drug List (PDL) Changes
October 2023. The following changes to the drug list are effective October 22, 2023:
Formulary Additions
- Amjevita prefilled syringe add Tier 3 with SP, quantity limit and prior authorization
- Cyltezo solution (auto injector kit and prefilled syringe) add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Empaveli solution add Tier 3 with SP and prior authorization
- Lupron depot injection kit add Tier 3 with SP and prior authorization
- Mekinist oral solution add Tier 3 with SP, quantity limit and prior authorization
- Miebo ophthalmic solution add Tier 3 with quantity limit and medical necessity prior authorization
- Mircera prefilled syringe add Tier 3 with SP
- Omeprazole suspension add Tier 3 with quantity limit
- Paxlovid therapy pack add Tier 0 with quantity over time limit
- Plerixafor solution add Tier 1 with SP
- Tafinlar soluble tablet add Tier 3 with SP, quantity limit and prior authorization
- Udenyca autoinjector add Tier 3 with SP and prior authorization
- Vyjuvek gel add Tier 3 with SP, quantity limit and prior authorization
- Zavzpret nasal solution add Tier 3 with quantity over time limit and medical necessity prior authorization
- Zejula tablet add Tier 3 with SP, quantity limit and prior authorization
- Zeposia starter kit add Tier 3 with SP, quantity limit and prior authorization
Quantity Limit
- Update quantity limit
- Dexmethylphenidate extended release capsule
- Focalin XR capsule
- Metformin modified release tablet
- Metformin osmotic release tablet
- Zejula capsule
Prior Authorization
- Add prior authorization
- Miacalcin injection solution
- Prevymis tablet
- Silenor tablet
- Remove prior authorization
- Dapsone 7.5% gel
- First-omeprazole suspension
- Hemangeol solution (for ages 12 months and younger)
- Metformin modified release tablet
- Tizanidine capsule
Step Therapy
- Step Therapy removal
- Silenor tablet
- Step Therapy update
- Doxepin tablet
Tier Update
- Advair HFA inhaler
- Breo Ellipta inhaler
- Flovent HFA inhaler
- Perforomist nebulizer solution
- Symbicort inhaler
Legacy Enhanced Drug List Removals
- Advair HFA inhaler
- BiDil tablet
- Breo Ellipta inhaler
- Daliresp tablet
- Flovent HFA inhaler
- Perforomist nebulizer solution
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2023. The following changes to the drug list are effective October 22, 2023:
Formulary Additions
- Auvi-Q autoinjector 0.1mg add Tier 3 with quantity over time limit
- Dapsone 7.5% gel add Tier 1
- Doxepin tablet add Tier 1 with quantity limit
- Empaveli solution add Tier 4 with SP and prior authorization
- Hemangeol solution add Tier 3 with prior authorization for those ages older than 12 months
- Lupron depot injection kit add Tier 4 with SP and prior authorization
- Mekinist oral solution add Tier 4 with SP, quantity limit and prior authorization
- Metformin modified release tablet add Tier 1 with quantity limit
- Omeprazole suspension add Tier 3 with quantity limit
- Paxlovid therapy pack add Tier 0 with quantity over time limit
- Plerixafor solution add Tier 4 with SP
- Tafinlar soluble tablet add Tier 4 with SP, quantity limit and prior authorization
- Udenyca autoinjector add Tier 4 with SP and prior authorization
- Vyjuvek gel add Tier 4 with SP, quantity limit and prior authorization
- Zejula tablet add Tier 4 with SP, quantity limit and prior authorization
- Zeposia starter kit add Tier 4 with SP, quantity limit and prior authorization
Prior Authorization
- Add prior authorization
- Prevymis tablet
- Remove prior authorization
- First-omeprazole suspension
- Tizanidine capsule
Quantity Limit update
- Dexmethylphenidate extended release capsule
Removed from Formulary
- Advair HFA inhaler; consider fluticasone-salmeterol inhaler, budesonide-formoterol inhaler, fluticasone furoate-vilanterol inhaler
- Breo Ellipta inhaler; consider fluticasone furoate-vilanterol inhaler, fluticasone-salmeterol inhaler, budesonide-formoterol inhaler
- Flovent HFA inhaler; consider fluticasone propionate HFA inhaler
- Gabitril tablet; consider tiagabine tablet
- Mozobil solution; consider plerixafor solution
- Symbicort inhaler; consider budesonide-formoterol inhaler, fluticasone furoate-vilanterol inhaler, fluticasone-salmeterol inhaler
- Zejula capsule; consider Zejula tablet
See the PacificSource Drug Lists page for the current drug list.