Updates on Existing Criteria:
May 2022. The following changes to criteria are effective May 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Amifampridine – remove Ruzurgi as it was removed from market and no longer available
- Avonex – Update covered uses and required medical information
- Axicabtagene Ciloleucel – update appropriate treatment regimen for indications
- Burosumab – update treatment regimen for Tumor Induced Osteomalacia
- Epoprostenol – Update required medical information for Pulmonary arterial hypertension (PAH)
- Hyaluronic Acid Derivatives – update approved indications
- Intravitreal Anti-VEGF Therapy – update to include new drug Vabysmo and clarify covered uses
- Miacalcin – update criteria for Paget’s disease of bone
- Opioid Quantity Above 100 Morphine Milligram Equivalents (MME) – MME limit reduced to 90 MME
- Rebif – update exclusion criteria
- Rituximab – clarified appropriate dosing for rheumatoid arthritis and coverage duration
- Targeted Immune Modulators – add new indication for Cosentyx (Enthesitis-Related Arthritis and Juvenile Psoriatic Arthritis), added Infliximab (J1745) to non-preferred medical drug list for all indications
- Trastuzumab – update required medical information
- Tyvaso – update exclusion criteria
Preferred Drug List (PDL) Changes
May 2022. The following changes to the drug list are effective May 22, 2022:
Formulary Additions
- Descovy tablet add Tier 3 with quantity limit
- Dhivy tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Lenalidomide capsule add Tier 1 with SP and prior authorization
- Naloxone prefilled syringe add Tier 1
- PreHevbrio injection add Tier 0 (ACA limitations may apply)
- Rabeprazole 10mg sprinkle capsule add Tier 1 with quantity limit
- Seglentis tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Soaanz tablet add Tier 3 with medical necessity prior authorization
- Talzenna capsule add Tier 3 with SP, quantity limit, partial fill and prior authorization
- Tarpeyo capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
- Vancocin capsule add Tier 3 with quantity over time limit
- Zimhi prefilled syringe add Tier 2 with quantity over time limit
Prior Authorization Update
- Add Prior Authorization (Medical Necessity)
- Calcipotriene-betamethasone dipropionate suspension
- Enstilar foam
- Taclonex suspension
Step Therapy Updates
- Remove Step Therapy
- Calcipotriene-betamethasone dipropionate suspension
- Enstilar foam
- Taclonex suspension
Quantity Limit Updates
- Rabeprazole 20mg tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
May 2022. The following changes to the drug list are effective May 22, 2022:
Formulary Additions
- Alogliptin-metformin tablet add Tier 1
- Descovy tablet add Tier 3 with quantity limit
- Lenalidomide capsule add Tier 4 with SP and prior authorization
- Naloxone prefilled syringe add Tier 1
- PreHevbrio injection add Tier 0 (ACA limitations may apply)
- Talzenna capsule add Tier 4 with SP, quantity limit, partial fill and prior authorization
- Tarpeyo capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
- Zimhi prefilled syringe add Tier 2 with quantity over time limit
Step Therapy Updates
- Remove step therapy
- Calcipotriene-betamethasone dipropionate suspension
- Enstilar foam
Prior Authorization Update
- Add Medical Necessity Prior Authorization
- Calcipotriene-betamethasone dipropionate suspension
- Enstilar foam
Quantity Limit Updates
- Rabeprazole tablet
See the PacificSource Drug Lists page for the current drug list.