Updates on Existing Criteria
May 2024. The following changes to criteria are effective May 22, 2024:
Prior Authorization Criteria – Clinical Updates
- Alosetron – updated prescriber restriction
- Amifampridine – updated required medical information and appropriate treatment
- Antiemetics – updated required medical information and appropriate treatment
- Apomorphine – clarified covered uses and updated required medical information
- Calcifediol – removed age restriction and updated appropriate treatment
- Cinacalcet – updated required medical information
- Duopa – clarified covered uses, updated required medical information, and appropriate treatment
- Eculizumab – updated required medical information, appropriate treatment, and clarified exclusion criteria
- Etelcalcetide – updated required medical information
- Inebilizumab-cdon – updated required medical information, appropriate treatment, and clarified exclusion criteria
- Lumasiran – renamed to RNA Interference Drugs for Primary Hyperoxaluria 1 and added coverage criteria for new drug Rivfloza
- Neonatal FC Receptor Antagonists – updated required medical information, appropriate treatment, and clarified exclusion criteria
- Nuplazid – clarified covered uses
- Parathyroid Hormone Analogs – removed age restriction, updated required medical information, and appropriate treatment
- Ravulizumab-cwvz – updated required medical information, appropriate treatment, and clarified exclusion criteria
- Romosozumab – updated appropriate treatment and clarified exclusion criteria
- Satralizumab-mwge – updated required medical information and clarified exclusion criteria
- Subcutaneous Immune Globulin – added HyQvia for chronic inflammatory demyelinating polyneuropathy (CIDP)
- Tralokinumab – update quantity limit for new pediatric indication
Preferred Drug List (PDL) Changes
May 2024. The following changes to the drug list are effective May 22, 2024:
Formulary Additions
- Agamree suspension add Tier 3 with SP, limited access, quantity limit and prior authorization
- Rivfloza (vial and prefilled syringe) add Tier 3 with SP, quantity limit and prior authorization
- Yuflyma auto-injector add Tier 3 with SP, quantity limit and medical necessity prior authorization
- Zilbrysq prefilled syringe add Tier 3 with SP, limited access, quantity limit and prior authorization
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
May 2024. The following changes to the drug list are effective May 22, 2024:
Formulary Additions
- Agamree suspension add Tier 4 with SP, limited access, quantity limit and prior authorization
- Rivfloza (vial and prefilled syringe) add Tier 4 with SP, quantity limit and prior authorization
- Zilbrysq prefilled syringe add Tier 4 with SP, limited access, quantity limit and prior authorization
See the PacificSource Drug Lists page for the current drug list.