Updates on Existing Criteria
June 2022. The following changes to criteria are effective June 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Abilify Maintena – added requirement of established tolerability to oral aripiprazole
- Actimmune – added dose rounding policy
- Antihemophilic Factors – update required medical information and appropriate treatment
- Cannabidiol – update required medical information and clarified appropriate dosing
- Cerliponase Alfa – updated required medical information
- Chelating Agents – clarified renewal criteria and quantity limits
- Myeloid Growth Factors – update to include Releuko as non-preferred product
- Oncology Agents – add Besremi to affected medications
- Ravulizumab – removed Soliris step through for diagnosis of PNH and aHUS
- Targeted Immune Modulators – update to include new indication of Ulcerative Colitis for Rinvoq
Step Therapy Criteria – Clinical Updates
- Antidiabetics – add exception applying to Jardiance for heart failure
Preferred Drug List (PDL) Changes
June 2022. The following changes to the drug list are effective June 22, 2022:
Formulary Additions
- Cibinqo tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Citalopram capsule add Tier 3
- Fleqsuvy suspension add Tier 3 with quantity limit and medical necessity prior authorization
- Hizentra prefilled syringe add Tier 3 with SP and prior authorization
- Ibsrela tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Moderna COVID (booster) vaccine add Tier 0 (ACA limitations may apply)
- Pfizer COVID 19 vaccine add Tier 0 (ACA limitations may apply)
- Pyrukynd tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Releuko solution add Tier 3 with SP and prior authorization
- Twyneo cream add Tier 3 with medical necessity prior authorization
- Vonvendi solution add Tier 3 with SP and prior authorization
Tier Update
- Combigan 0.2-0.5% solution
- Restasis Emulsion 0.05%
- Restasis MultiDose Emulsion 0.05%
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
June 2022. The following changes to the drug list are effective June 22, 2022:
Formulary Additions
- First Progesterone vaginal suppository add Tier 3 with prior authorization
- Hizentra prefilled syringe add Tier 4 with SP and prior authorization
- Moderna COVID-19 (booster) add Tier 0 (ACA limitations may apply)
- Pfizer COVID-19 add Tier 0 (ACA limitations may apply)
- Pyrukynd tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
Removed from Formulary
- Combigan solution; consider brimonidine-timolol 0.2-0.5% solution
- Restasis emulsion and Restasis multidose; consider cyclosporine 0.05% emulsion, Xiidra solution
See the PacificSource Drug Lists page for the current drug list.