Updates on Existing Criteria
January 2023. The following changes to criteria are effective January 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Adcirca – add new product Tadliq
- Addyi & Vyleesi – update covered uses to define acquired and generalized hypoactive sexual desire disorder (HSDD)
- Asciminib – update prescriber restriction
- Dupilumab – add new indication of prurigo nodularis
- Esbriet – rename Pirfenidone and update required medical information
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – update exclusion criteria to include those in current remission or controlled disease
- Medical Necessity – update required medical information
- Mulpleta – rename Lusutrombopag and define covered uses
- Myeloid Growth Factors – add new products Fylnetra and Rolvedon as non-preferred products
- Oral Testosterone – add new product Kyzatrex as preferred product
- Ravicti – update covered uses and age restriction
- Romiplostim – update reauthorization criteria
- Rufinamide - update prescriber restriction
- Siltuximab – update covered uses, required medical information and appropriate treatment regimen
- Sipuleucel-T – update required medical information
- Somatostatin Analogs - update covered uses, required medical information and appropriate treatment regimen
- Subcutaneous Immune Globulin – update required medical information for Primary Immunodeficiency (PID) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
- Tafamidis – update required medical information and covered uses
- Targeted Immune Modulators – add criteria for Generalized Pustular Psoriasis Flare
- Thalidomide – update covered uses and required medical information
- Tisagenlecleucel – update required medical information and appropriate treatment regimen
- Tobramycin Inhalation – update appropriate treatment regimen section
- Uplizna - update prescriber restriction
- Verteporfin - update prescriber restriction
- Verteporfin Injection – update appropriate treatment regimen and update prescriber restriction
Preferred Drug List (PDL) Changes
January 2023. The following changes to the drug list are effective January 22, 2023:
Formulary Additions
- Auvelity tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Efavirenz-emtricitabine-tenofovir DF tablet add Tier 1
- FreeStyle Libre 3 Sensor add Tier 2 with quantity limit and prior authorization
- Fylnetra prefill syringe add Tier 3 with SP and prior authorization
- Kyzatrex capsule add Tier 3 with SP, quantity limit and prior authorization
- Nucala prefilled syringe add Tier 3 with SP, quantity limit and prior authorization
- Pheburane oral pellet add Tier 3 with SP and medical necessity prior authorization
- Quetiapine fumarate tablet add Tier 1
- Relyvrio packet add Tier 3 with SP, quantity limit and prior authorization
- Rolvedon prefilled syringe add Tier 3 with SP and prior authorization
- Tadliq oral suspension add Tier 3 with SP, quantity limit and prior authorization
- Zonisade oral suspension add Tier 3 with quantity limit and medical necessity prior authorization
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
January 2023. The following changes to the drug list are effective January 22, 2023:
Formulary Additions
- Aminocaproic oral solution add Tier 1
- Bexarotene capsule add Tier 4, SP, quantity limit and prior authorization
- FreeStyle Libre 3 sensor add Tier 2 with quantity limit and prior authorization
- Icosapent ethyl capsule add Tier 1 with quantity limit
- Kyzatrex capsule add Tier 3 with quantity limit and prior authorization
- Nucala prefilled syringe add Tier 4, SP, quantity limit and prior authorization
- Quetiapine fumarate tablet add Tier 1
- Relyvrio packet add Tier 4, SP, quantity limit and prior authorization
- Tadliq oral suspension add Tier 4, SP, quantity limit and prior authorization
Removed from Formulary
- Targretin capsule; consider bexarotene capsule
- Vascepa 0.5gm capsule; consider Icosapent ethyl 0.5gm capsule
See the PacificSource Drug Lists page for the current drug list.