Updates on Existing Criteria
January 2024. The following changes to criteria are effective January 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Cholbam – remove dosing and add reauthorization criteria
- Dinutuximab – update required medical information and age restriction
- Fenfluramine – update covered uses, remove age restriction and updated coverage duration
- Galafold – add required medical information for coverage and update exclusion criteria
- Ilaris – update to include new indication and coverage criteria for the treatment of gout flare
- Intravitreal Anti-VEGF Therapy – update to include new product Eylea HD as non-preferred product
- Kalydeco – update required medical information and coverage duration
- Macrilen – update covered uses and remove dosing
- Mechlorethamine – update appropriate treatment and exclusion criteria
- Medical Necessity – add Airsupra, Lodoco
- Naxitamab – update covered uses and required medical information
- Olipudase Alfa – update required medical information
- Oncology Agents – add Elrexfio, Akeega, Ojjaara, Iobenguane I-131, Azedra, Melphalan, Evomela
- Reblozyl – update to include new indication
- Rufinamide – update to include required medical information for LGS indication
- Sacrosidase – update covered uses and required medical information
- Sebelipase Alfa – update diagnostic criteria for coverage and add reauthorization criteria
- Selumetinib – update required medical information, exclusion criteria and appropriate treatment
- Somavert – update required medical information and coverage duration
- Teduglutide – update required medical information and appropriate treatment regimen
- Zorbtive – add step through first line treatment for short bowel syndrome (SBS)
Preferred Drug List (PDL) Changes
January 2024. The following changes to the drug list are effective January 22, 2024:
Formulary Additions
- Ak-Fluror solution add Tier 1
- Amphetamine-Dextroamphetamine 3-Bead ER capsule add Tier 1 with quantity limit and prior authorization (new starts only for ages 6 to 12 years)
- Balfaxar solution add Tier 3
- Clindamycin phos-Benzoyl Peroxide gel add Tier 1 with medical necessity prior authorization
- Fluorescein solution add Tier 1
- Fluticasone propionate diskus add Tier 1 with quantity limit
- Hyrimoz solution add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Jesduvroq tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Kalydeco packet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Ojjaara tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Pitavastatin tablet add Tier 1 with quantity limit
- Rykindo suspension add Tier 3 with quantity limit
- Sohonos capsule add Tier 3 with SP, quantity limit and prior authorization
- Spironolactone oral suspension add Tier 1 with medical necessity prior authorization
- Trientine capsule add Tier 1 with prior authorization
- Veopoz solution add Tier 3 with SP, limited access and prior authorization
Quantity Limit
- Add quantity limit
- Clemastine fumarate tablet
- Remove quantity limit
- Leflunomide tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
January 2024. The following changes to the drug list are effective January 22, 2024:
Formulary Additions
- Akeega tablet add Tier 4 with SP, limited access, partial fill, quantity limit and prior authorization
- Amphetamine-Dextroamphetamine 3-Bead ER capsule add Tier 1 with quantity limit and prior authorization (new starts only for ages 6 to 12 years)
- Fluticasone propionate diskus add Tier 1 with quantity limit
- Kalydeco packet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Ojjaara tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Pitavastatin tablet add Tier 1 with quantity limit
- Rykindo suspension add Tier 3 with quantity limit
- Sohonos capsule add Tier 3 with SP, quantity limit and prior authorization
- Treprostinil solution add Tier 4 with SP and prior authorization
- Veopoz solution add Tier 3 with SP, limited access and prior authorization
Quantity Limit
- Remove quantity limit
- Leflunomide tablet
Removed from Formulary
- Remodulin solution; consider treprostinil solution
See the PacificSource Drug Lists page for the current drug list.