Updates on Existing Criteria
July 2021. The following changes to criteria are effective July 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Arcalyst – add new indication of Recurrent Pericarditis
- Juxtapid – combine policy with new drug Evkeeza
- Leuprolide – clarified required medical information for all indications
- Tyvaso - add new indication of Pulmonary Hypertension associated with Interstitial Lung Disease (WHO Group 3)
Preferred Drug List (PDL) Changes
July 2021. The following changes to the drug list are effective July 22, 2021:
Formulary Additions
- Accutane capsule add Tier 1
- Cyclophosphamide tablet add Tier 2
- Elepsia XR tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Emtricitabine-Tenofovir tablet add Tier 1
- Femynor tablet add Tier 0 (ACA limitations may apply)
- Hetlioz LQ suspension add Tier 3 with LA, quantity limit and prior authorization
- Isotretinoin 25mg and 35mg capsule add Tier 1 with medical necessity prior authorization
- Isotretinoin 40mg capsule add Tier 1
- Kalliga tablet add Tier 0 (ACA limitations may apply)
- Loteprednol etabonate gel add Tier 1
- Lyllana twice weekly patch add Tier 1 with prior authorization for new starts under age of 18 years
- Meloxicam capsule add Tier 1 with medical necessity prior authorization
- Ozempic solution pen-injector add Tier 2 with quantity limit and step therapy
- Paroex solution add Tier 1
- Ponvory tablet add Tier 3 with SP, quantity limit and prior authorization
- Potassium chloride solution add Tier 1
- Reltone capsule add Tier 3 with medical necessity prior authorization
- Tri-Femynor tablet add Tier 0 (ACA limitations may apply)
- Tri-Lo-Mili tablet add Tier 0 (ACA limitations may apply)
- Tri-VyLibra Lo tablet add Tier 0 (ACA limitations may apply)
- Xtandi tablet add Tier 3 with prior authorization and partial fill
Prior Authorization Updates
- Add Medical Necessity
- Doryx delayed release 200mg tablet
- Doxycycline hyclate delayed release 200mg tablet
Tier Updates
- Truvada tablet
Removed from Formulary
- Bevyxxa capsule
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
July 2021. The following changes to the drug list are effective July 22, 2021:
Formulary Additions
- Cyclophosphamide tablet add Tier 2
- Emtricitabine-tenofovir tablet add Tier 1
- Kalliga tablet add Tier 0 (ACA limitations may apply)
- Loteprednol etabonate gel add Tier 1
- Ozempic solution pen-injector add Tier 2 with quantity limit and step therapy
- Paroex solution add Tier 1
- Potassium chloride oral solution/packet add Tier 1
- Quinidine sulfate tablet add Tier 1
- Tri-Femynor tablet add Tier 0 (ACA limitations may apply)
- Tri-Lo-Mili tablet add Tier 0 (ACA limitations may apply)
- Tri-VyLibra Lo tablet add Tier 0 (ACA limitations may apply)
Removed from Formulary
- Truvada tablet; consider Emtricitabine-Tenofovir tablet
See the PacificSource Drug Lists page for the current drug list.