Updates on Existing Criteria
July 2023. The following changes to criteria are effective July 22, 2023:
Prior Authorization Criteria – Clinical Updates
- Antihemophilic Factors – update to include Altuviiio
- Brexanolone – update required medical information and add age restriction
- Cialis – update covered uses and appropriate treatment regimen
- Elosulfase Alfa – update diagnostic criteria for covered use
- Erectile Dysfunction – updated covered uses
- Galsulfase – replace current criteria with updated format
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – update required medical information to define metformin trial and failure, update required baseline A1c requirement
- Lusutrombopag – remove exclusion criteria and update required medical information
- Maralixibat – remove age restriction
- Nuplazid – add required medical information
- Ofev – update required medical information for each covered diagnosis
- Oral Testosterone – update appropriate treatment regimen
- Romiplostim – update required medical information including baseline platelet count
- Tarpeyo – update appropriate treatment and covered uses
- Trientine – add Cuvrior and update required medical information and appropriate treatment
Preferred Drug List (PDL) Changes
July 2023. The following changes to the drug list are effective July 22, 2023:
Formulary Additions
- Altuviiio solution add Tier 3 with SP and prior authorization
- Budesonide rectal foam add Tier 1
- Clenpiq solution add Tier 0
- Cuvrior tablet add Tier 3 with SP and prior authorization
- Diclofenac 3% gel add Tier 1 with quantity limit
- Filspari tablet add Tier 3 with SP, quantity limit and prior authorization
- Iheezo gel add Tier 3 with medical necessity prior authorization
- Joenja tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Levamlodipine tablet add Tier 1 with quantity limit and medical necessity prior authorization
- Tezspire auto-injector add Tier 3 with SP, quantity limit and prior authorization
Tier Update
- Uceris rectal foam
Prior Authorization
- Remove medical necessity
- Kerendia tablet
- Remove prior authorization
- Fenoprofen 400mg capsules
- Ribavirin capsule
- Ribavirin tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
July 2023. The following changes to the drug list are effective July 22, 2023:
Formulary Additions
- Altuviiio solution add Tier 4 with SP and prior authorization
- Budesonide rectal foam add Tier 1
- Clenpiq solution add Tier 0
- Cuvrior tablet add Tier 4 with SP and prior authorization
- Diclofenac 3% gel add Tier 1 with quantity limit
- Filspari tablet add Tier 4 with SP, quantity limit and prior authorization
- Joenja tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Tezspire auto-injector add Tier 4 with SP, quantity limit and prior authorization
Prior Authorization Removal
- Ribavirin capsule
- Ribavirin tablet
Removed from Formulary
- Uceris foam; consider budesonide foam
See the PacificSource Drug Lists page for the current drug list.