Updates on Existing Criteria
April 2022. The following changes to criteria are effective April 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Botox – update appropriate treatment regimen to include coverage for anal fissures
- Dalfampridine – Update to include step through generic for brand coverage and update required medical information
- Opzelura – add Adbry as step through requirement
- Soliris – rename Eculizumab and update required medical information
- Targeted Immune Modulators – add new indication for Orencia IV solution, Xeljanz, Rinvoq and Skyrizi with allowed dosing for all, updated Xeljanz/Xeljanz XR/Rinvoq question for step through TNF inhibitor
- Voxelotor – update age restriction, add soluble tablets and require current weight
Prior Authorization Criteria – Clerical Update
- Laronidase – minor grammar corrections
Preferred Drug List (PDL) Changes
April 2022. The following changes to the drug list are effective April 22, 2022:
Formulary Additions
- Adbry solution add Tier 3 with SP, quantity limit and prior authorization
- Albuterol sulfate HFA inhaler add Tier 1 with quantity limit
- Azathioprine tablet (75mg and 100mg) add Tier 1 with medical necessity prior authorization
- Brimonidine-Timolol ophthalmic solution add Tier 1
- Cortrophin gel add Tier 3 with SP, limited access and medical necessity prior authorization
- Cyclosporine ophthalmic emulsion add Tier 1
- Cyclosporine ophthalmic emulsion in Klarity add Tier 2
- Dartisla ODT tablet add Tier 3 with medical necessity prior authorization
- DesRx gel add Tier 1 with medical necessity prior authorization
- Fenofibrate micronized capsule add Tier 1
- Leqvio solution add Tier 3 with SP, limited access, quantity limit and prior authorization
- Lubiprostone capsule add Tier 1 with quantity limit and step therapy
- Naloxone nasal spray add Tier 1 with quantity over time limit
- Oxbryta soluble tablet add Tier 3 with SP, quantity limit and prior authorization
- Paroxetine oral suspension add Tier 1
- Recorlev tablet add Tier 3 with SP, quantity limit and prior authorization
- Sajazir solution add Tier 1 with SP and prior authorization
- Taysofy capsule add Tier 0 (ACA limitations may apply)
- Tezspire solution add Tier 3 with SP, quantity limit and prior authorization
- Triamcinolone ointment add Tier 1
- Tritocin ointment add Tier 1
Prior Authorization Update
- Add Prior Authorization (Medical Necessity)
- Panretin gel
Step Therapy Update
- Remove Step Therapy
- Lokelma packet
Quantity Limit Updates
- Add Quantity Limit
- Amitiza capsule
- Azelastine-Fluticasone nasal spray
- Dymista nasal spray
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
April 2022. The following changes to the drug list are effective April 22, 2022:
Formulary Additions
- Adbry solution add Tier 4 with SP, quantity limit and prior authorization
- Albuterol HFA inhaler add Tier 1 with quantity limit
- Azelastine-Fluticasone nasal spray add Tier 1 with quantity limit
- Brimonidine-Timolol solution add Tier 1
- Cyclosporine ophthalmic emulsion add Tier 1
- Lubiprostone capsule add Tier 1 with quantity limit and step therapy
- Naloxone nasal spray add Tier 1 with quantity over time limit
- Oxbryta soluble tablet add Tier 4 with SP, quantity limit and prior authorization
- Paroxetine oral suspension add Tier 1
- Recorlev tablet add Tier 4 with SP, quantity limit and prior authorization
- Sajazir solution add Tier 4 with SP and prior authorization
- Taysofy capsule add Tier 0 (ACA limitations may apply)
- Tezspire solution add Tier 4 with SP, quantity limit and prior authorization
Removed from Formulary
- Paxil oral suspension; consider paroxetine oral suspension
See the PacificSource Drug Lists page for the current drug list.