Updates on Existing Criteria
September 2022. The following changes to criteria are effective September 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Adempas – rename Riociguat and update required medical information for Pulmonary arterial hypertension (PAH)
- Bevacizumab – add new biosimilar Alymsys as non-preferred product
- Continuous Glucose Monitors – add exclusion criteria for pregnancy and dialysis
- Dupilumab – update age for atopic dermatitis indication
- Eculizumab – update to include step through Ultomiris for gMG
- Ergot Alkaloids – update required medical information
- Histrelin – updated required medical information for gender dysphoria
- Hycamtin – remove stand-alone policy and add to General Oncology criteria
- Immune Globulin – Update criteria for Primary immunodeficiency (PID) and Chronic Lymphocytic Leukemia with associated hypogammaglobulinemia
- Intravitreal Anti-VEGF Therapy – add Byooviz as non-preferred product for all indication and update Beovu new indication of diabetic macular edema (DME)
- Kalydeco – rename Ivacaftor, remove dosing and update required medical information
- Kimmtrak – remove stand-alone policy and add to General Oncology criteria
- Makena – remove appropriate treatment regimen preterm labor
- Maribavir – update appropriate treatment regimen
- Mavenclad – rename Cladribine and update exclusion criteria
- Natalizumab – expanded required medical information for each indication
- Niraparib – update appropriate treatment regimen
- Orkambi – update required medical information
- Ravulizumab – add Generalized Myasthenia Gravis (gMG) indication and dosing
- Risdiplam – update required medical information to include motor function for symptomatic patients
- Rituximab – add coverage criteria for Thrombocytopenia in patients with ITP indication
- Symdeko – update required medical information
- Targeted Immune Modulators – add Skyrizi to preferred pharmacy drug for Crohn’s Disease, update Simponi Aria as preferred medical drug for all indications, update Enthesitis-Related Arthritis (ERA) and Juvenile Psoriatic Arthritis (JPsA) section
- Teduglutide – update prescriber restriction
- Trikafta – update required medical information
- Tyvaso – update appropriate treatment regimen
- Vestronidase Alfa – remove maximum dosing limit
- Vistogard – update appropriate treatment regimen
Preferred Drug List (PDL) Changes
September 2022. The following changes to the drug list are effective September 22, 2022:
Formulary Additions
- Epsolay cream add Tier 3 with quantity limit and step therapy
- Lyvispah packet add Tier 3 with quantity limit and medical necessity prior authorization
- Mounjaro solution add Tier 3 with quantity limit and medical necessity prior authorization
- Skyrizi solution add Tier 3 with SP, quantity limit and prior authorization
- Verkazia ophthalmic emulsion add Tier 3 with quantity limit and medical necessity prior authorization
- Ztalmy suspension add Tier 3 with SP, quantity limit and prior authorization
Quantity Limit Update
- Valsartan oral solution
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
September 2022. The following changes to the drug list are effective September 22, 2022:
Formulary Additions
- Skyrizi solution add Tier 4 with SP, quantity limit and prior authorization
- Ztalmy suspension add Tier 4 with SP, quantity limit and prior authorization
See the PacificSource Drug Lists page for the current drug list.