April 2024 Drug List Change Notification (Commercial)

February 20, 2024

Updates on Existing Criteria

April 2024. The following changes to criteria are effective April 22, 2024:

Prior Authorization Criteria – Clinical Updates

Alemtuzumab – update covered uses and renewal criteria
Antihemophilic Factors – update to include new indication of Wilate for routine prophylaxis and criteria for coverage
Belzutifan – update to include criteria for new indication of refractory advanced or metastatic clear cell renal carcinoma
Bimatoprost Implants – replace policy with “Prostaglandin Implants” which includes coverage criteria for new drug iDose TR
CGRP Inhibitors – update required medical information for episodic migraine prevention
Cholbam – update covered uses and required medical information including coverage for Peroxisomal disorders (such as Zellweger spectrum disorders)
Cladribine – update appropriate treatment regimen and remove dosage table
Droxidopa – updated covered uses and required medical information to define severe symptomatic orthostatic hypotension
Evkeeza and Juxtapid – update covered uses and required medical information
Evolocumab – update to NSO (New Starts Only), replace current policy with updated formatting and include criteria for homozygous familial hypercholesterolemia
Fluocinolone Ocular Implant – define covered uses and update appropriate treatment regimen
Ilaris – update required medical information including added diagnosis of Mevalonate Kinase Deficiency (MKD)
Immune Globulin – update covered uses, coverage durations and appropriate treatment regimen for PANS/PANDAS indication
Intravitreal Anti-VEGF Therapy – remove continuation allowance for those established on non-preferred products such as Lucentis and Susvimo
Isavuconazonium Sulfate – update criteria to required confirmation of invasive aspergillosis or invasive mucormycosis
Medical Necessity – add brand Soolantra cream, Saphris
Mometasone Sinus Implant – update covered uses and required medical information
Natalizumab – update required medical information and reauthorization criteria
Oncology Agents – add Bosulif capsule, Turalio capsule
Oxervate – update covered uses and required medical information for stage 2 and stage 3 neurotrophic keratitis
Oxybates – update required medical information and exclusion criteria
Pegcetacoplan rename Proximal Complement Inhibitor and include coverage criteria for new drug Fabhalta, update exclusion criteria
Ponvory – remove age restriction
Rituximab – update covered uses and remove allowance to continue on non-preferred product if established on treatment
Solriamfetol – update exclusion criteria, required medical information for all indications and appropriate treatment regimen
Stiripentol – update required medical information and appropriate treatment regimen
Targeted Immune Modulators – update preferred products to include Hyrimoz (Cordavis), adalimumab-adaz, update coverage criteria for Otezla for plaque psoriasis and update required oral treatment for diagnosis of rheumatoid arthritis
Tarpeyo – update to new indication
Tasimelteon – update required medical information, appropriate treatment regimen for both Non-24 and SMS and update exclusion criteria
Teriflunomide – update exclusion criteria
Topical Antipsoriatics – update to include new formulation of Zoryve (foam) including indication of seborrheic dermatitis
Verteporfin – addition of dose rounding requirement if within 10% of prescribed dose
VMAT2 Inhibitors – update exclusion criteria
Xifaxan – update appropriate treatment regimen for diagnosis of SIBO

Step Therapy Criteria Updates

Antidepressants – update fluvoxamine ER to step 1
Atypical Antipsychotics – update asenapine to step 1 (remove Saphris)
Constipation Agents – remove criteria
Migraine Agents – update almotriptan tablet to step 1
Overactive Bladder – update darifenacin to step 1
Rosacea Topical – update ivermectin 1% cream to step 1 (remove Soolantra)

Prior Authorization Criteria – Clerical Updates

Benralizumab – replace current policy with updated formatting
Dupilumab – updated formatting of required medical information and appropriate treatment regimen
Inclisiran - replace current policy with updated formatting
Intravitreal Complement Inhibitors – correct generic name of Izervay
Mepolizumab – replace current policy with updated formatting
Omalizumab - replace current policy with updated formatting
Palforzia – replace current policy with updated formatting
Reslizumab - replace current policy with updated formatting
Siponimod – update formatting and abbreviations
Tezepelumab-EKKO - replace current policy with updated formatting
Turalio – remove stand-alone criteria

Preferred Drug List (PDL) Changes

April 2024. The following changes to the drug list are effective April 22, 2024:

Formulary Additions

Bosulif capsule add Tier 3 with SP, partial fill, quantity limit, and prior authorization
Dapagliflozin tablet add Tier 1 with quantity limit
Dapagliflozin-metformin extended-release tablet add Tier 1 with quantity limit
Dextramphetamine tablet add Tier 1 with quantity limit and prior authorization for new starts only (ages 6 to 12 years)
Fabhalta capsule add Tier 3 with SP, limited access, quantity limit, and prior authorization
Gabapentin (once daily) tablet add Tier 1 with quantity limit and step therapy
Gabapentin solution add Tier 1
Gabapentin tablet add Tier 3
Gralise tablet add Tier 3 with quantity limit and step therapy
Hulio prefilled syringe kit add Tier 3 with SP, quantity limit, and medical necessity prior authorization
Humalog tempo pen add Tier 3 with medical necessity prior authorization
Hyrimoz (Cordavis) solution add Tier 3 with SP, quantity limit, and prior authorization
Iwilfin tablet add Tier 3 with SP, limited access, quantity limit, and prior authorization
Penbraya suspension add Tier 0 (ACA limitations may apply)
Wainua auto injector add Tier 3 with SP, limited access, quantity limit, and prior authorization
Wilate kit add Tier 3 with SP and prior authorization
Zituvio tablet add Tier 3 with medical necessity prior authorization
Zoryve foam add Tier 3 with quantity limit and prior authorization

Quantity Limit

Quantity Limit Removal
- Quetiapine fumarate extended-release tablet
- Seroquel XR tablet
Quantity Limit Update
- Dextroamphetamine tablet
- Zenzedi tablet

Prior Authorization

Prior Authorization Update to New Starts Only
- Repatha (auto injector, prefilled syringe, cartridge)
Prior Authorization Removal
- Insulin aspart prot and aspart
- Insulin aspart (penfill, flexpen, and vial)
- Novolog Relion
- Novolog Mix 70/30 Relion

Step Therapy

Step Therapy Update (step 2 to step 1)
- Almotriptan malate tablet
- Darifenacin ER tablet
- Asenapine maleate sublingual tablet
- Ivermectin cream
- Fluvoxamine maleate ER capsule
- Farxiga tablet
Step Therapy Removal
- Linzess capsule

Tier Update

Chlorzoxazone tablet
Clemastine fumarate syrup
Glatiramer solution
Glatopa solution
Insulin aspart (penfill, flexpen, and vial)
Insulin aspart prot and aspart
Lamotrigine starter kit
Novolog Mix 70/30 Relion
Novolog Relion
Sulfadiazine tablet

Value Based Preventive Drug List Removals

Farxiga tablet
Xiguo XR tablet

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes