Updates on Existing Criteria
April 2021. The following changes to criteria are effective April 22, 2021:
Preauthorization Criteria – Clinical Updates
- Antiemetics – add criteria for Akynzeo oral treatment
- Antithymocyte Globulin – Update dosing for renal transplant rejection
- Belimumab – Add new indication of Lupus Nephritis
- Blinatumomab – Clarified maximum dosing for relapsed/refractory disease
- C1 Esterase Inhibitor, Ecallantide, Lanadelumab – combine to include create Hereditary Angioedema (HAE) indications/treatments
- Emicizumab – Add required baseline factor requirement for coverage
- Growth Hormone – Update required medical information for diagnosis of Turner’s syndrome
- Omalizumab – Update criteria for diagnosis and required previous treatment in Chronic Idiopathic Urticaria
- Rituximab – Update preferred products to include Riabni, move Truxima to non-preferred
- Tasimelteon – Add new indication of nighttime sleep disturbances in Smith-Magenis Syndrome (SMS)
- Trastuzumab – Update preferred products to include Ogivri and Kanjinti only
- Trikafta – Update required medical information
Preferred Drug List (PDL) Changes
April 2021. The following changes to the drug list are effective April 22, 2021:
Formulary Additions
- Abiraterone 500mg tablet add Tier 1 with SP and medical necessity preauthorization
- Budesonide extended release 9mg tablet add Tier 1 with quantity limit and medical necessity preauthorization
- Doryx tablet add Tier 3 with medical necessity preauthorization
- Doxycycline delayed release tablet add Tier 3 with medical necessity preauthorization
- Fosfomycin oral powder add Tier 1 with quantity over time limit
- Gemmily capsule add Tier 0 (ACA limitations may apply)
- Gemtesa tablet add Tier 3 with quantity limit and step therapy
- Iclevia tablet add Tier 0 (ACA limitations may apply)
- Iclusig tablet add Tier 3 with SP, limited access, quantity limit and preauthorization
- Levothyroxine capsule add Tier 1 with quantity limit
- Merzee capsule add Tier 0 (ACA limitations may apply)
- Metyrosine capsule add Tier 1 with medical necessity preauthorization
- Mitigare capsule add Tier 3 with medical necessity preauthorization
- Norethindrone-Ethyinyl Estradiol-FE capsule add Tier 0 (ACA limitations may apply)
- Ongentys capsule add Tier 3 with quantity limit
- Orgovyx tablet add Tier 3 with SP, limited access, quantity limit and preauthorization
- Orladeyo capsule add Tier 3 with SP, limited access, quantity limit and preauthorization
- Prolate solution add Tier 3 with medical necessity preauthorization
- Retacrit solution add Tier 2 with SP
- Rufinamide suspension add Tier 1 with preauthorization
- Setlakin tablet add Tier 0 (ACA limitations may apply)
- Taytulla capsule add Tier 0 (ACA limitations may apply)
- Tetracaine ophthalmic solution 0.5% add Tier 1
- Thyquidity solution add Tier 3
- Timolol ophthalmic PF solution add Tier 1
- Timolol ophthalmic solution add Tier 1
- Tobramycin nebulization solution add Tier 1 with SP and preauthorization
- Vaxelis suspension add Tier 0 (ACA limitations may apply)
- Wynzora cream add Tier 3 with medical necessity preauthorization
- Xeljanz solution add Tier 3, SP, quantity limit and preauthorization
- Zokinvy capsule add Tier 3 with SP, limited access and preauthorization
Quantity Limit Updates
- Add Quantity Limit
- Alecensa capsule
- Febuxostat tablet
- Monurol packet
- Tirosint capsule
- Uloric tablet
- Update Quantity Limit
- Esomeprazole capsule
- Iclusig tablet
- Nexium capsule
Removed from Formulary
- Paregoric (Opium Tincture)
- Uryl tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
April 2021. The following changes to the drug list are effective April 22, 2021:
Formulary Additions
- Alecensa capsule add Tier 3 with SP, quantity limit and preauthorization
- Fosfomycin powder packet add Tier 1 with quantity over time limit
- Gemmily capsule add Tier 0 (ACA limitations may apply)
- Iclevia tablet add Tier 0 (ACA limitations may apply)
- Iclusig tablet add Tier 4 with SP, limited access, quantity limit and preauthorization
- Levothyroxine capsule add Tier 1 with quantity limit
- Merzee capsule add Tier 0 (ACA limitations may apply)
- Norethindrone-Ethyinyl Estradiol-FE capsule add Tier 0 (ACA limitations may apply)
- Ongentyx capsule add Tier 3 with quantity limit
- Orgovyx tablet add Tier 4 with SP, limited access, quantity limit and preauthorization
- Orladeyo capsule add Tier 4 with SP, limited access, quantity limit and preauthorization
- Retacrit solution add Tier 2 with SP
- Rufinamide suspension add Tier 4 with preauthorization
- Setlakin tablet add Tier 0 (ACA limitations may apply)
- Tavaborole solution add Tier 1 with medical necessity preauthorization
- Timolol ophthalmic PF solution add Tier 1
- Timolol ophthalmic solution add Tier 1
- Vaxelis suspension add Tier 0 (ACA limitations may apply)
- Xeljanz solution add Tier 4 with SP, quantity limit and preauthorization
- Zokinvy capsule add Tier 4 with SP, limited access and preauthorization
Quantity Limit Updates
- Add Quantity Limit
- Febuxostat tablet
- Update Quantity Limit
- Esomeprazole capsule
- Iclusig tablet
Removed from Formulary
- Banzel suspension; consider rufinamide suspension
- Istalol solution; consider timolol ophthalmic solution, betaxolol ophthalmic solution
- Kerydin solution; consider ciclopirox gel, ciclopirox cream, ciclopirox suspension, nystatin cream
- Taytula capsule; consider Gemmily capsule, Merzee capsule
- Timoptic Ocudose; consider Timolol ophthalmic PF solution
See the PacificSource Drug Lists page for the current drug list.