Updates on Existing Criteria:
September 2021. The following changes to criteria are effective September 22, 2021:
Prior Authorization Criteria – Clinical Updates
- Botox – Update exclusion criteria
- Krystexxa – For chronic gout, clarified required trial requirements with allopurinol and febuxostat
- Ocrelizumab – Clarify coverage for relapsing forms of multiple sclerosis
- Oncology Agents – Add new drug Rybrevant
- Oxlumo – Update required medical information and removed age restriction
- Ozanimod – Add new indication of Ulcerative Colitis with required medical information
- Palivizumab – Clarify age restriction
- Prolia – Remove required information except diagnosis (osteoporosis) and approved dosing
- Remodulin – Update requirement for acute vasoreactivity testing
- Targeted Immune Modulators – Updated age and dosing for Cosentyx and required CASPAR criteria for Psoriatic Arthritis
- Vestronidase Alfa – Update required medical information
Prior Authorization Criteria – Clerical Update
- Spinraza – Update name to Nusinersen
Preferred Drug List (PDL) Changes
September 2021. The following changes to the drug list are effective September 22, 2021:
Formulary Additions
- Accrufer capsule – Add Tier 3 with quantity over time limit
- Clindavix kit – Add Tier 3 with medical necessity prior authorization
- Cosentyx prefilled syringe – Add Tier 3 with SP, quantity limit and prior authorization
- Exservan film – Add Tier 3 with quantity limit and medical necessity prior authorization
- Prolia prefilled syringe – Add Tier 3 with SP
Prior Authorization Update
- Remove
- Prolia solution
Quantity Limit Updates
- Add
- Genvoya tablet
- Symfi Lo tablet
- Symfi tablet
- Symtuza tablet
- Update
- Bosulif tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
September 2021. The following changes to the drug list are effective September 22, 2021:
Formulary Additions
- Symfi Lo tablet – Add Tier 3 with quantity limit
- Symfi tablet – Add Tier 3 with quantity limit
- Prolia Prefilled syringe – Add Tier 4 with SP
- Accrufer capsule – Add Tier 3 with quantity over time limit
- Cosentyx Prefilled syringe – Add Tier 4 with SP, quantity limit and preauthorization
Prior Authorization Update
- Remove
- Prolia solution
Quantity Limit Updates
- Add
- Genvoya tablet
- Plegridy starter pack
- Update
- Bosulif tablet
Removed from Formulary
- Lotemax Gel; consider loteprednol etabonate ophthalmic gel
See the PacificSource Drug Lists page for the current drug list.