Drug List Change Notification

August 2020. The following changes to criteria are effective August 22, 2020.

Updates on Existing Criteria

Preauthorization Criteria – Clinical Updates

  • Crysvita – rename Burosumab and update appropriate treatment regimen
  • FDA Approved Drug – updated to include new indications not yet reviewed by plan
  • Imatinib – remove stand-alone policy and add to General Oncology Agents PA
  • Imbruvica – remove stand-alone policy and add to General Oncology Agents PA
  • Parathyroid Hormone Analogs – add new drug Bonsity and update appropriate treatment regimen
  • Reblozyl – update to include new indication of anemia due to myelodysplastic syndromes
  • Relistor – rename Methylnaltrexone and replace Amitiza with Linzess on required medication trial
  • Targeted Immune Modulators – Update Crohn’s Disease section to include severe/high risk disease

Preauthorization Criteria – Clerical Updates

  • Besponsa – rename Inotuzumab Ozogamicin
  • Ibrance – rename Palbociclib
  • Idhifa – rename Enasidenib
  • Jetrea – rename Ocriplasmin
  • Kanuma – rename Sebelipase Alfa
  • Kymriah – rename Tisagenlecleucel
  • Movantik – rename Naloxegol
  • Nerlynx – rename Neratinib
  • Piqray – rename Alpelisib
  • Provenge – rename Sipuleucel-T
  • Sprycel – rename Dasatinib
  • Sylvant – rename Siltuximab
  • Syprine – rename Trientine
  • Targretin – rename Bexarotene
  • Tasigna – rename Nilotinib
  • Tecentriq – rename Atezolizumab
  • Thalomid – rename Thalidomide
  • Unituxin – rename Dinutuximab
  • Valchlor – rename Mechlorethamine
  • Vectibix- rename Panitumumab
  • Verzenio – rename Abemaciclib
  • Vitrakvi – rename Larotrectinib
  • Zejula – rename Niraparib

Preferred Drug List (PDL) Changes

Formulary Additions

  • DayVigo tablet add Tier 3 with quantity limit and step therapy
  • Diclovix M therapy pack add Tier 3 with medical necessity preauthorization
  • Gvoke HypoPen pack add Tier 2 with quantity over time limit
  • Isturisa tablet add Tier 3 with SP, quantity limit and preauthorization
  • Koselugo capsule add Tier 3 with SP, quantity limit and preauthorization
  • Nexlizet tablet add Tier 3 with quantity limit and medical necessity preauthorization
  • Osmolex ER therapy pack with quantity limit and step therapy
  • Pemazyre tablet add Tier 3 with SP, quantity limit and preauthorization
  • Retevmo capsule add Tier 3 with SP, quantity limit and preauthorization
  • Tabrecta tablet add Tier 3 with SP, quantity limit and preauthorization
  • Tukysa tablet add Tier 3 with SP, quantity limit and preauthorization

Step Therapy Updates

  • Rapaflo capsule
  • Rybelsus tablet
  • Silodosin capsule

Quantity Limit Updates

  • Add quantity limit:
    • Alosetron tablet
    • Lotronex tablet
  • Update quantity limit:
    • Gvoke Prefilled Syringe
    • Imbruvica capsule
    • Imbruvica tablet

Tier Updates

  • Primaquine phosphate tablet
  • Rhopressa solution
  • Rocklatan solution
  • Rybelsus tablet

Preauthorization Updates

  • Remove preauthorization:
    • Rocklatan solution
    • Rhopressa solution
    • Rybelsus tablet

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes

Formulary Additions

  • DayVigo tablet add Tier 3 with quantity limit and step therapy
  • Gvoke HypoPen pack add Tier 2 with quantity over time limit
  • Isturisa tablet add Tier 4 with SP, quantity limit and preauthorization
  • Koselugo capsule add Tier 4 with SP, quantity limit and preauthorization
  • Osmolex ER therapy pack add Tier 3 with quantity limit and step therapy
  • Pemazyre tablet add Tier 4 with SP, quantity limit and preauthorization
  • Retevmo capsule add Tier 4 with SP, quantity limit and preauthorization
  • Rhopressa solution add Tier 2
  • Rocklatan solution add Tier 2
  • Rybelsus tablet add Tier 2 with quantity limit and step therapy
  • Tabrecta tablet add Tier 4 with SP, quantity limit and preauthorization
  • Tukysa tablet add Tier 4 with SP, quantity limit and preauthorization

Step Therapy Update

  • Silodosin capsule

Quantity Limit Update

  • Add quantity limit:
    • Alosetron tablet
  • Update quantity limit:
    • Gvoke Prefilled Syringe
    • Imbruvica tablet

Tier Update

  • Primaquine phosphate tablet

See the PacificSource Drug Lists page for the current drug list.

InTouch for Members

Last updated 6/18/2020