Updates on Existing Criteria
September 2024. The following changes to criteria are effective September 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Anifrolumab – update appropriate treatment and coverage duration
- Belimumab – update required medical information, appropriate treatment, exclusion criteria, and coverage duration
- Cysteamine – update required medical information, appropriate treatment, and remove exclusion criteria
- Difelikefalin – update required medical information, appropriate treatment, coverage duration, and remove age restriction
- Eplontersen, Patisiran, Vutrisiran – combine to one policy
- Erythropoiesis Stimulating Agents (ESAs) – update appropriate treatment
- Penicillamine – update required medical information and appropriate treatment
- Ravicti – update appropriate treatment, exclusion criteria, and remove age restriction
- Siltuximab – update appropriate treatment and coverage duration
- Sodium Phenylbutyrate – update covered uses and appropriate treatment
- Sparsentan – update required medical information, appropriate treatment, and age restriction
- Tafamidis – update required medical information and appropriate treatment
- Targeted Immune Modulators – add Rinvoq to preferred pharmacy drug for juvenile idiopathic arthritis and update quantity limitations
- Tolvaptan – update required medical information and appropriate treatment
- Trientine – update required medical information and appropriate treatment
Preferred Drug List (PDL) Changes
September 2024. The following changes to the drug list are effective September 22, 2024:
Formulary Additions
- Adalimumab-adbm injection add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Adalimumab-fkjp injection add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Caverject injection add Tier 3 with prior authorization
- Cyltezo injection add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Deflazacort suspension add Tier 3 with quantity limit and prior authorization
- Ingrezza Sprinkle capsule add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Libervant film add Tier 3 with quantity limit and medical necessity prior authorization
- Liraglutide pen add Tier 1 with quantity limit and prior authorization
- Ojemda tablet and suspension add Tier 3 with SP, limited access, quantity limit and prior authorization
- Omvoh prefilled syringe add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Ormalvi tablet add Tier 1 with SP and medical necessity prior authorization
- Rinvoq LQ solution add Tier 3 with SP, quantity limit and prior authorization
- Vijoice packet add Tier 3 with SP, quantity limitation and prior authorization
- Xolremdi capsule add Tier 3 with SP, quantity limit and prior authorization
Prior Authorization
- Add Medical Necessity
- Depen tablet
- Emflaza suspension
- Myrbetriq tablet
- Penicillamine tablet
- Versacloz suspension
- Add
- Aranesp injection
- Epogen injection
- Mircera prefilled syringe
- Procrit injection
Quantity Limit
- Add
- Alunbrig tablet
- Kevzara injection
- Update
- Omvoh autoinjector
Step Therapy
- Remove
- Myrbetriq tablet
Tier Update
- Myrbetriq tablet
Removed From Formulary
- Exkivity capsule
- Hydroxyprogesterone injection
- Tegsedi prefilled syringe
- Ukoniq tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
September 2024. The following changes to the drug list are effective September 22, 2024:
Formulary Additions
- Deflazacort suspension add Tier 4 with quantity limit and prior authorization
- Libervant film add Tier 4 with quantity limit
- Ojemda tablet and suspension add Tier 4 with SP, limited access, quantity limit and prior authorization
- Rinvoq LQ solution add Tier 4 with SP, quantity limit and prior authorization
- Vijoice packet add Tier 4 with SP, quantity limitation and prior authorization
- Xolremdi capsule add Tier 4 with SP, quantity limit and prior authorization
Prior Authorization
- Remove
- Cystagon capsule
Quantity Limit
- Add
- Alunbrig tablet
Tier Update
- Mavyret tablet
Removed From Formulary
- Emflaza suspension; consider deflazacort, prednisone
- Exkivity capsule
- Gralise tablet; consider gabapentin, duloxetine, pregabalin
- Myrbetriq tablet; consider darifenacin, oxybutynin, solifenacin, tolterodine, trospium, fesoterodine, mirabegron
- Penicillamine tablet; consider penicillamine capsule
- Tegsedi prefilled syringe
- Ukoniq tablet
See the PacificSource Drug Lists page for the current drug list.