Updates on Existing Criteria:
May 2021. The following changes to criteria are effective May 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Carbaglu – rename Carglumic Acid and update to include new indication of acute hyperammonemia due to propionic academia (PA) or methylmalonic academia (MMA)
- Romiplostim – update to cover new indication of acute exposure to myelosuppressive radiation
- Immune Globulin – Add coverage for Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)
- Taliglucerase – remove required step through Cerezyme and exclude concurrent Cerdelga therapy
- Qutenza – remove from Medical Necessity criteria and add stand-alone policy to require step through compendia supported first line therapies
Preferred Drug List (PDL) Changes
May 2021. The following changes to the drug list are effective May 22, 2021:
Formulary Additions
- Acyclovix therapy pack add Tier 3 with medical necessity prior authorization
- Dermalid therapy pack add Tier 3 with medical necessity prior authorization
- Droxidopa capsule add Tier 1 with SP and prior authorization
- Ivermectin lotion add Tier 1
- Klisyri ointment add Tier 3 with medical necessity prior authorization
- Lupkynis capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
- Lyleq tablet add Tier 0 (ACA drug, limitations may apply)
- Nitazoxanide tablet add Tier 1 with quantity over time limit
- Nylia tablet add Tier 0 (ACA drug, limitations may apply)
- Plegridy prefilled syringe add Tier 3 with SP, quantity limit and prior authorization
- Tepmetko tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Ukoniq tablet add Tier 3 with SP, limited access, quantity limit and prior authorization
- Verquvo tablet add Tier 3 with quantity limit
- Vesicare LS suspension add Tier 3 with medical necessity prior authorization
- Vesicare tablet add Tier 3 with quantity limit
- Vocabria tablet add Tier 3 with SP, limited access and quantity limit
Quantity Limit Updates
- Update Quantity Limit
- Edarbi tablet
- Xalkori capsule
Tier Update
- Vascepa capsule
Prior Authorization Updates
- Add Prior Authorization
- Carbaglu tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
May 2021. The following changes to the drug list are effective May 22, 2021:
Formulary Additions
- Cipro HC Otic suspension add Tier 3 with medical necessity prior authorization
- Droxidopa capsule add Tier 4 with SP and prior authorization
- Ivermectin lotion add Tier 1
- Lupkynis capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
- Lyleq tablet add Tier 0 (ACA drug, limitations may apply)
- Nitazoxanide tablet add Tier 1 with quantity over time limit
- Nylia tablet add Tier 0 (ACA drug, limitations may apply)
- Plegridy prefilled syringe add Tier 4 with SP, quantity limit and prior authorization
- Tepmetko tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Ukoniq tablet add Tier 4 with SP, limited access, quantity limit and prior authorization
- Verquvo tablet add Tier 3 with quantity limit
- Vocabria tablet add Tier 4 with SP, limited access and quantity limit
Quantity Limit Updates
- Remove Quantity Limit
- Irbesartan tablet
- Update Quantity Limit
- Edarbi tablet
- Xalkori capsule
Tier Update
- Vascepa capsule
Removed from Formulary
- Alinia tablet; consider nitazoxanide tablet
- Northera capsule; consider droxidopa capsule
- Sklice lotion; consider ivermectin lotion
See the PacificSource Drug Lists page for the current drug list.