Updates on Existing Criteria
April 2023. The following changes to criteria are effective April 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Alemtuxumab - define covered uses and treatment regimen
- CGRP Inhibitors – add combination use with another CGRP inhibitor exclusion and update coverage requirement for Episodic Cluster Headache
- Cladribine – define covered uses and treatment regimen
- Corlanor – update covered uses appropriate treatment regimen
- Deflazacort – update required prednisone trial and reauthorization criteria
- Difelikefalin – update prescriber restriction and reauthorization criteria
- Dojolvi – update required medical information and include trial requirement for medium chain triglyceride (MCT)
- Gilenya – rename Fingolimod, update covered uses and add coverage criteria for Tascenso ODT
- Mavacamten – update covered uses and appropriate treatment regimen
- Medical Necessity – remove Brexafemme and add stand-alone criteria
- Mometasone Sinus Implant – Update required medical information and covered use
- Myeloid Growth Factors – add Stimufend as non-preferred product
- Naloxegol – update covered uses and appropriate treatment regimen
- Natalizumab – update covered uses and appropriate treatment regimen
- Ocrelizumab - define covered uses and treatment regimen
- Oncology Agents – add Lunsumio, Krazati, Rezlidhia, Carvykti, Abecma, Yescarta, Tecartus, Breyanzi, Kymriah (remove stand-alone criteria for all)
- Opioid Quantity Above 90 Morphine Milligram Equivalents (MME) – add tapentadol and oxycodone myristate to conversion table
- Parathyroid Hormone Analogs – update covered uses and required medical information
- Triptorelin – update covered uses and include coverage for Gender Dysphoria, add required medical information for Central Precocious Puberty (CPP)
Preferred Drug List (PDL) Changes
April 2023. The following changes to the drug list are effective April 22, 2023:
Formulary Additions
- Krazati tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Lanreotide Acetate solution add Tier 3 with SP and prior authorization
- Mifepristone tablet add Tier 1
- Rebyota suspension add Tier 3 with SP, limited access and prior authorization
- Rezlidhia capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
- Stimufend solution add Tier 3 with SP and prior authorization
- Sunlenca solution add Tier 3 with SP and prior authorization
- Sunlenca tablet pack add Tier 3 with SP, quantity over time limit and prior authorization
- Tascenso ODT tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Topiramate ER capsule add Tier 1 with medical necessity prior authorization
- Tramadol oral solution add Tier 1 with quantity limit and medical necessity prior authorization
Prior Authorization
- Remove Medical Necessity (PA remains)
- Brexafemme tablet
- Add Medical Necessity
- Gilenya capsule
- Xeloda tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
April 2023. The following changes to the drug list are effective April 22, 2023:
Formulary Additions
- Brexafemme tablet add Tier 3 with quantity over time limit and prior authorization
- Krazati tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Lanreotide Acetate solution add Tier 4 with SP and prior authorization
- Mifepristone tablet add Tier 1
- Rezlidhia capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
- Stimufent solution add Tier 4 with SP and prior authorization
- Sunlenca solution add Tier 4 with SP and prior authorization
- Sunlenca tablet pack add Tier 4 with SP, quantity over time limit and prior authorization
- Tascenso ODT tablet add Tier 4 with SP, quantity limit and prior authorization
Removed from Formulary
- Gilenya 0.50mg capsule; consider fingolimod 0.5mg capsule
- Methylphenidate 72mg OSM extended-release tablet; consider methylphenidate 36mg OSM extended release (ER) tablet, amphetamine-dextroamphetamine ER capsule, dextroamphetamine sulfate ER capsule, dexmethylphenidate ER capsule, methylphenidate ER (CD) capsule, methylphenidate ER (LA) capsule, methylphenidate ER tablet
See the PacificSource Drug Lists page for the current drug list.