Updates on Existing Criteria
August 2021. The following changes to criteria are effective August 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Antidiabetic Step Therapy – Add exception bullet for Farxiga new indication of chronic kidney disease
- Chelating Agents – Update age restriction and include coverage for sickle cell disease or other anemias
- Romosozumab – Clarify exception for those with T-score less than -3.5
Preferred Drug List (PDL) Changes
August 2021. The following changes to the drug list are effective August 22, 2021:
Formulary Additions
- Brinzolamide 1% ophthalmic solution add Tier 1
- Calcipotriene foam add Tier 1 with medical necessity prior authorization
- Clobetex therapy pack add Tier 3 with medical necessity prior authorization
- Deferasirox packet add Tier 1 with medical necessity prior authorization
- Dolishale tablet add Tier 0 (ACA limitations may apply)
- Epiduo Forte gel add Tier 3
- Fluoxetine (PMDD) tablet add Tier 1 with medical necessity prior authorization
- Humira Pen injector kit add Tier 3 with SP, quantity limit and prior authorization
- Hydrocodone bitartrate extended release add Tier 1 with step therapy, prior authorization may apply
- Levonorgestrel-ethinyl estradiol tablet add Tier 0 (ACA limitations may apply)
- Levo-T tablet add Tier 1
- Nextstellis tablet add Tier 0 (ACA limitations may apply)
- Orphenadrine-aspirin-caffeine tablet add Tier 1 with medical necessity prior authorization
- Praluent Auto injector add Tier 3 with medical necessity prior authorization
- Pregabalin extended release tablet add Tier 1 with medical necessity prior authorization
- Qelbree extended release capsule add Tier 3 with quantity limit and medical necessity prior authorization
- Roszet tablet add Tier 3 with quantity limit
- Skyrizi solution add Tier 3 with SP, quantity limit and prior authorization
- Xpovio therapy pack add Tier 3 with SP, limited access, quantity limit and prior authorization
- Zafemy patch add Tier 0 (ACA limitations may apply)
- Zegalogue solution add Tier 3 with quantity over time limit
Prior Authorization Updates
- Add Medical Necessity
- Exjade soluble tablet
- Jadenu tablet
Step Therapy Updates
- Remove Step Therapy
- Dificid suspension
- Dificid tablet
Quantity Limit Updates
- Add Quantity Over Time Limit
- Dificid suspension
- Dificid tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
August 2021. The following changes to the drug list are effective August 22, 2021:
Formulary Additions
- Brinzolamide 1% ophthalmic solution add Tier 1
- Dolishale tablet add Tier 0 (ACA limitations may apply)
- Hetlioz LQ suspension add Tier 4 with SP, limited access, quantity limit and prior authorization
- Humira pen injector kit add Tier 4 with SP, quantity limit and prior authorization
- Levonorgestrel-ethinyl estradiol tablet add Tier 0 (ACA limitations may apply)
- Nextstellis tablet add Tier 0 (ACA limitations may apply)
- Skyrizi solution add Tier 4 with SP, quantity limit and prior authorization
- Xpovio therapy pack add Tier 4 with SP, limited access, quantity limit and prior authorization
- Zafemy patch add Tier 0 (ACA limitations may apply)
- Zegalogue solution add Tier 3 with quantity over time limit
Step Therapy Updates
- Remove Step Therapy
- Dificid solution
- Dificid tablet
Quantity Limit Updates
- Add Quantity Over Time Limit
- Dificid suspension
- Dificid tablet
Removed from Formulary
- Azopt suspension; consider Brinzolamide 1% ophthalmic solution
See the PacificSource Drug Lists page for the current drug list.