March 2024 Drug List Change Notification (Commercial)

January 19, 2024

Updates on Existing Criteria

March 2024. The following changes to criteria are effective March 22, 2024:

Prior Authorization Criteria – Clinical Updates

Addyi & Vyleesi – update required medical information, exclusion criteria and coverage duration
Brexanolone – rename “Gaba-A Receptor Modulators” and add criteria for coverage of Zurzuvae
Cannabidiol – update coverage duration
Cialis – update required medical information
Dornase Alfa – remove exclusion criteria
Emapalumab – update required medical information and appropriate treatment regimen
Erectile Dysfunction – update required medical information
Fenfluramine – update covered uses and coverage duration
Ganaxolone – update coverage duration
Growth Hormone (Somatropin) Injectables – update required medical information and appropriate treatment regimen
Intravitreal Anti-VEGF Therapy – update to include new indication for Vabysmo
Kalydeco – remove stand-alone policy and combine to create “CFTR Modulators”
Medical Necessity – add Jylamvo, Coxanto, Oxaprozin capsule, Abrilada kit, Cabtreo gel, Vevye, Korlym, Helioz capsule
Ocrelizumab – update required medical information
Oncology Agents – add Truqap, Augtyro, Loqtorzi, Xalkori sprinkle
Orkambi – remove stand-alone policy and combine to create “CFTR Modulators”
Rilonacept – update required medical information and coverage duration
Stiripentol – update appropriate treatment regimen
Symdeko – remove stand-alone policy and combine to create “CFTR Modulators”
Trikafta – remove stand-alone policy and combine to create “CFTR Modulators”
Vigabatrin – update required medical information and appropriate treatment regimen

Preferred Drug List (PDL) Changes

March 2024. The following changes to the drug list are effective March 22, 2024:

Formulary Additions

Abrilada kit add Tier 3 with SP, quantity limit and medical necessity prior authorization
Amjevita prefilled syringe add Tier 3 with SP, quantity limit and medical necessity prior authorization
Augtyro capsule add Tier 3 with SP, quantity limit and prior authorization
Cabtreo gel add Tier 3 with medical necessity prior authorization
Coxanto capsule add Tier 3 with medical necessity prior authorization
EnilloRing add Tier 0 (ACA restrictions may apply) with quantity over time limit
Humira kit add Tier 3 with SP, quantity limit and prior authorization
Hydroxocobalamin solution add Tier 1
Jylamvo solution add Tier 3 with medical necessity prior authorization
Ogsiveo tablet add Tier 3 with SP, quantity limit and prior authorization
Oxaprozin capsule add Tier 1 with medical necessity prior authorization
Teriparatide pen injector add Tier 3 with SP and prior authorization
Truqap tablet add Tier 3 with SP, quantity limit and prior authorization
Turqoz tablet add Tier 0 (ACA restrictions may apply)
Vevye solution add Tier 3 with quantity over time limit and medical necessity prior authorization
Voquezna tablet add Tier 3 with quantity over time limit and step therapy
Xalkori sprinkle capsule add Tier 3 with SP, partial fill, quantity limit and prior authorization
Xphozah tablet add Tier 3 with quantity limit and prior authorization
Zurzuvae capsule add Tier 3 with SP, quantity over time limit and prior authorization

Quantity Limit Removal

Solifenacin succinate tablet
Vesicare tablet

Prior Authorization

Prior Authorization Removal
- Dexlansoprazole capsule
Prior Authorization Addition
- Hetlioz capsule (medical necessity)
- Korlym tablet

Step Therapy Update

Lubiprostone capsule

Tier Update

Pitavastatin tablet

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes