Updates on Existing Criteria
November 2022. The following changes to criteria are effective November 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Actiq – added exclusion criteria
- Cialis – updated prescriber restrictions
- Enasidenib – remove stand-alone and add to Oncology Agents criteria
- Ibrance - remove stand-alone and add to Oncology Agents criteria
- Kalydeco - removed baseline eye exam requirement
- Lisocabtagene Maraleucel – update appropriate treatment regimen to include new indication
- Oncology Agents – add Clolar to affected medications
- Onpattro – defined FAP and updated exclusion criteria
- Opzelura – update exclusion criteria to include cosmetic conditions such as vitiligo
- Orkambi – removed baseline eye exam requirement
- Oxervate – updated appropriate treatment regimen
- Parathyroid Hormone Analogs – update required medical information and clarified exclusion criteria
- Pegasys – update covered uses
- PegIntron – update covered uses
- Penoxybenzamine – updated required medical information and appropriate use
- Stiripentol – update covered uses and exclusion criteria
- Symdeko - removed baseline eye exam requirement
- Trikafta - removed baseline eye exam requirement
- Verzenio - remove stand-alone and add to Oncology Agents criteria
- Vtama – rename “Vtama & Zoryve” and include criteria for Zoryve coverage
Clerical Update
- Tecartus – rename Brexucabtagene Autoleucel
Preferred Drug List (PDL) Changes
November 2022. The following changes to the drug list are effective November 22, 2022:
Formulary Additions
- Aspruzyo spinkle packet add Tier 3 with quantity limit and medical necessity prior authorization
- Caplyta capsule add Tier 3 with quantity limit and step therapy
- Comirnaty vaccine add Tier 0 (ACA limitations may apply)
- Hyftor gel add Tier 3 with SP, limited access, quantity limit and prior authorization
- Methylin tablet add Tier 3 with prior authorization for ages 6 to 12 years (new starts only)
- Priorix vaccine add Tier 0 (ACA limitations may apply)
- Venlafaxine besylate extended release tablet add Tier 3 with quantity limit and medical necessity prior authorization
- Voquezna therapy pack add Tier 3 with medical necessity prior authorization
- Zoryve cream add Tier 3 with quantity limit and prior authorization
Prior Authorization Updates
- Add Medical Necessity
- Paromomycin capsule
- Ranexa extended release tablet
Quantity Limit
- Add quantity limit
- Catapres-TTS patch
- Cleocin T solution
- Fortamet tablet
- Gabitril tablet
- Lovenox solution
- Methylin solution
- Ovide lotion
- Patanase nasal solution
- Skelaxin tablet
- Tribenzor tablet
- Update quantity limit
- Methergine tablet
- Methylergonovine maleate tablet
- Remove quantity limit
- Ezetimibe tablet
Tier Update
- APO-varenicline tablet
- Chantix starting pack
- Chantix tablet
Removed from Formulary
- Cyclafem tablet
- Tri-Previfem tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
November 2022. The following changes to the drug list are effective November 22, 2022:
Formulary Additions
- Caplyta capsule add Tier 3 with quantity limit and step therapy
- Comirnaty vaccine add Tier 0 (ACA limitations may apply)
- Hyftor gel add Tier 4 with SP, limited access, quantity limit and prior authorization
- Priorix vaccine add Tier 0 (ACA limitations may apply)
- Valtoco nasal spray add Tier 3 with quantity over time limit
- Zoryve cream add Tier 3 with quantity limit and prior authorization
Prior Authorization (add medical necessity)
- Paromomycin capsule
Quantity Limit Removal
- Ezetimibe tablet
Removed from Formulary
- APO-Varenicline tablet; consider varenicline tartrate tablet or starter pack
- Chantix tablet and starter pack; consider varenicline tartrate tablet or starter pack
- Cyclafem
- Tri-Previfem
See the PacificSource Drug Lists page for the current drug list.