Updates on Existing Criteria
June 2024. The following changes to criteria are effective June 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Avatrombopag – update appropriate treatment, add exclusion criteria and remove age restriction
- Beremagene Geperpavec-svdt – update appropriate treatment and add exclusion criteria
- Bevacizumab – update appropriate treatment
- Caplacizumab-yhdp – update require medical information, appropriate treatment and exclusion criteria
- Continuous Glucose Monitors – update appropriate treatment, exclusion criteria, and coverage through pharmacy benefits
- Defibrotide – update appropriate treatment and remove exclusion criteria
- Dupilumab – update required medical information and appropriate treatment
- Eltrombopag – update appropriate treatment, add exclusion criteria and remove age restriction
- Enfuvirtide – update required medical information and appropriate treatment
- Fostamatinib – update appropriate treatment, add exclusion criteria and remove age restriction
- Larotrectinib – update appropriate treatment
- Lenacapavir – update required medical information and appropriate treatment
- Omalizumab – add new indication, required medical information, and appropriate treatment
- Pedmark – remove age restriction
- Pegasys – update required medical information and appropriate treatment
- Phesgo - update appropriate treatment
- Rethymic – add covered use and update required medical information
- Rituximab – update required medical information and appropriate treatment
- Romiplostim – update appropriate treatment and exclusion criteria
- Spravato – update required medical information and exclusion criteria
- Targeted Immune Modulators – add Cosentyx intravenous to non-preferred medical drug list and remove Humira from preferred drug list
- Teprotumumab-trbw – update required medical information, appropriate treatment, and exclusion criteria
- Trastuzumab – update appropriate treatment
- Trogarzo – add covered uses, update required medical information and appropriate treatment
- Vistogard – update appropriate treatment and add exclusion criteria
- Xgeva – update required medical information
Preferred Drug List (PDL) Changes
June 2024. The following changes to the drug list are effective June 22, 2024:
Formulary Additions
- Bromfenac ophthalmic solution add Tier 1
- Cabenuva injection add Tier 3
- Cyanocobalamin nasal spray add Tier 1 with medical necessity prior authorization
- Dabigatran etexilate mesylate capsule add Tier 1
- Deflazacort tablet add Tier 3, quantity limit and prior authorization
- Eohilia suspension add Tier 3 with quantity limit and medical necessity prior authorization
- Filsuvez gel add Tier 3 with SP, limited access, quantity limit and prior authorization
- Hemlibra solution add Tier 3 with SP, and prior authorization
- Indomethacin suspension add Tier 1
- Loteprednol etabonate suspension add Tier 1
- Mifepristone 300 mg tablet add Tier 1 with SP and medical necessity prior authorization
- Nitroglycerin ointment add Tier 1
- Opill tablet add Tier 0 (ACA limitations may apply)
- Podofilox gel add Tier 1
- Risperidone microspheres extended-release suspension add Tier 1, quantity limit
- Udenyca Onbody prefilled syringe add Tier 3 with SP, and prior authorization
- Wegovy pen add Tier 3 with quantity limit and medical necessity prior authorization
- Xolair auto injector solution add Tier 3 with SP, quantity limit and prior authorization
- Zymfentra pen add Tier 3 with SP, quantity limit and medical necessity prior authorization
Prior Authorization
- Add Medical Necessity
- Humira
Quantity Limit
- Update quantity limit
- Xolair solution
- Add quantity limit
- Mekinist 0.5 mg tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
June 2024. The following changes to the drug list are effective June 22, 2024:
Formulary Additions
- Cabenuva injection add Tier 3
- Deflazacort tablet add Tier 4, limited access, quantity limit and prior authorization
- Filsuvez gel add Tier 4 with SP, limited access, quantity limit and prior authorization
- Gabapentin (Once daily) tablet add Tier 1 with quantity limit and step therapy
- Hemlibra solution add Tier 4 with SP and prior authorization
- Indomethacin suspension add Tier 1
- Loteprednol etabonate ophthalmic suspension add Tier 1
- Nitroglycerin ointment add Tier 1
- Opill tablet add Tier 0 (ACA limitations may apply)
- Podofilox gel add Tier 1
- Risperidone microspheres extended-release suspension add Tier 1 and quantity limit
- Udenyca Onbody prefilled syringe add Tier 4 with SP and prior authorization
- Xolair auto injector add Tier 4 with SP, quantity limit and prior authorization
Quantity Limit
- Update quantity limit
- Xolair solution
- Add quantity limit
- Mekinist 0.5 mg tablet
Removed from Formulary
- Alrex ophthalmic suspension; consider loteprednol etabonate ophthalmic suspension
- Condylox gel; consider podofilox gel
- Gralise tablet; consider gabapentin (once daily) tablet, gabapentin (capsule or tablet), duloxetine capsule, pregabalin capsule
- Humira injection; consider Hadlima, Hyrimoz (Cordavis manufacturer), adalimumab-adaz
- Indocin suspension; consider indomethacin suspension
- Rectiv ointment; consider nitroglycerin ointment
See the PacificSource Drug Lists page for the current drug list.