Updates on Existing Criteria
September 2023. The following changes to criteria are effective September 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Bezlotoxumab – update required medical information
- Botox – added exclusion of combination use with CGRP for migraine prevention
- Burosumab – update appropriate treatment and exclusion criteria
- Calcifediol – updated required medical information and removed dosing
- Diroximel Fumarate – update coverage requirement with step through available generic products
- Enfuviride – added covered uses and required medical information, removed weight restriction
- Enzyme Replacement Therapy (ERT) For Fabry Disease - (remove current Fabrazyme policy) and update to include both Fabrazyme and Elfabrio
- Etelcalcetide – update required medical information and covered uses
- Flucytosine – clarified covered uses
- Ganaxolone – removed dosing and updated appropriate treatment regimen
- Growth Hormones (somatropin) injectables – update to include coverage of Sogroya
- Kalydeco – update covered uses and age restriction
- Monomethyl Fumarate - update coverage requirement with step through available generic products
- Oncology Agents – update to include Epkinly
- Ozanimod - update coverage requirement with step through available generic products
- Pegloticase – replace current criteria with updated format and additional reauthorization criteria
- Penicillamine – update covered uses, coverage duration and required medical information
- Phosphodiesterase-5 (PDE-5) Enzyme Inhibitors for Pulmonary Arterial Hypertension – (remove current Adcirca and Revatio policies) update to include Liqrev
- Rethymic – update requirement for genetic testing and appropriate treatment regimen
- Siponimod - update coverage requirement with step through available generic products
- Targeted Immune Modulators – update to include Rinvoq for Crohn’s Disease
- Teptrotumumab-TRBW – update required medical information
- Teriflunomide - update coverage requirement with step through available generic products
- Xeomin, Dysport and Myobloc – updated exclusion criteria
Preferred Drug List (PDL) Changes
September 2023. The following changes to the drug list are effective September 22, 2023:
Formulary Additions
- Desmopressin nasal solution add Tier 3 with SP
- Elfabrio solution add Tier 3 with SP and prior authorization
- Inpefa tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Kalydeco packet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Liqrev suspension add Tier 3 with SP and prior authorization
- Sogroya solution add Tier 3 with SP and prior authorization
- Uzedy suspension add Tier 3 with medical necessity prior authorization
- Veozah tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Zolpidem capsule add Tier 3 with quantity limit and medical necessity prior authorization
Quantity Limit
- Update Quantity Limit
- Rinvoq 45mg tablet
Prior Authorization
- Add medical necessity
- Ampyra tablet
- Add prior authorization
- Fuzeon solution
- Remove prior authorization
- Auvi-Q solution
- Dalfampridine extended-release tablet
- Dimethyl fumarate capsule
- Fingolimod 0.5mg capsule
- Stimate nasal solution
Removed from Formulary
- Diclofenac 1% gel
- Esomeprazole magnesium DR 20mg capsule
- G-levocarnitine solution
- Imbruvica 540mg tablet
- Nexium DR 20mg capsule
- Olopatadine 0.1% solution
- Olopatadine 0.2% solution
- Patanol solution
- Pazeo solution
- Voltaren 1% gel
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
September 2023. The following changes to the drug list are effective September 22, 2023:
Formulary Additions
- Desmopressin nasal solution add Tier 4 with SP
- Elfabrio solution add Tier 4 with SP and prior authorization
- Kalydeco packet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Liqrev suspension add Tier 4 with SP and prior authorization
- Sogroya solution add Tier 4 with SP and prior authorization
Prior Authorization Removal
- Dalfampridine extended-release tablet
- Dimethyl fumarate capsule
- Fingolimod 0.5mg capsule
- Stimate nasal solution
Quantity Limit Update
- Rinvoq 45mg tablet
Removed from Formulary
- Diclofenac 1% gel
- Esomeprazole magnesium DR 20mg capsule
- G-levocarnitine solution
- Imbruvica 540mg tablet
- K-Bicarb capsule
- Olopatadine 0.1% solution
- Olopatadine 0.2% solution
See the PacificSource Drug Lists page for the current drug list.