Updates on Existing Criteria
The following changes to criteria are effective October 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Arikayce – update covered uses, required medical information, and age restriction
- Bedaquiline, Pretomanid – combine to one policy
- Belimumab – update appropriate treatment and age restriction
- Botox – update appropriate treatment and exclusion criteria
- Burosumab – update required medical information and age restriction
- Calcitonin Gene-Related Peptide (CGRP) Inhibitors – update appropriate treatment and exclusion criteria
- Cerliponase Alfa – update required medical information and age restriction
- Edaravone – update required medical information and appropriate treatment
- Enzyme Replacement Therapy (ERT) For Fabry Disease, Galafold – combine to one policy
- Neonatal FC Receptors Antagonists – update required medical information and appropriate treatment
- Oncology Agents – add new drugs Rytelo and Hepzato
- Pegloticase – update required medical information
- Primary Biliary Cholangitis Agents – combine policy from Obeticholic Acid and add new drug Iqirvo
- Strensiq – update required medical information, appropriate treatment, and coverage duration
- Targeted Immune Modulators – add Skyrizi for new indication of ulcerative colitis
- Tofersen – update covered uses, required medical information, and appropriate treatment
- Vijoice – update covered uses, required medical information, and appropriate treatment
Preferred Drug List (PDL) Changes
October 2024. The following changes to the drug list are effective October 22, 2024:
Formulary Additions
- Austedo XR extended release tablet (30 mg, 36 mg, 42 mg, 48 mg) add Tier 3 with SP, quantity limit and prior authorization
- Capvaxive vaccine add Tier 0 (ACA vaccine)
- Duvyzat suspension add Tier 3 with SP, quantity limit and prior authorization
- Entresto Sprinkle capsule add Tier 3 with quantity limit
- Iqirvo tablet add Tier 3 with SP, quantity limit and prior authorization
- Ivabradine tablet add Tier 1 with quantity limit and prior authorization
- Jynneos vaccine add Tier 0 (ACA vaccine)
- L-Glutamine powder add Tier 1 with SP, quantity limit and step therapy
- Mresvia vaccine add Tier 0 (ACA vaccine)
- Myhibbin suspension add Tier 3 with medical necessity prior authorization
- Tiopronin tablet add Tier 1 with medical necessity prior authorization
Tier Update
- Lagevrio capsule
Removed from Formulary
- Aduhelm solution
- Austedo Titration Kit
- Farydak capsule
- Kisqali Femara Pack
- Truseltiq capsule
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2024. The following changes to the drug list are effective October 22, 2024:
Formulary Additions
- Austedo XR extended release tablet (30 mg, 36 mg, 42 mg, 48 mg) add Tier 4 with SP, quantity limit and prior authorization
- Capvaxive vaccine add Tier 0 (ACA vaccine)
- Duvyzat suspension add Tier 4 with SP, quantity limit and prior authorization
- Entresto Sprinkle capsule add Tier 3 with quantity limit
- Iqirvo tablet add Tier 4 with SP, quantity limit and prior authorization
- Ivabradine tablet add Tier 1 with quantity limit and prior authorization
- Jynneos vaccine add Tier 0 (ACA vaccine)
- L-Glutamine powder add Tier 3 with SP, quantity limit and step therapy
- Mresvia vaccine add Tier 0 (ACA vaccine)
Tier Update
- Lagevrio capsule
- Sofosbuvir-Velpatasvir tablet
Removed from Formulary
- Aduhelm solution
- Austedo Titration Kit
- Farydak capsule
- Truseltiq capsule
See the PacificSource Drug Lists page for the current drug list.