Additional August 2025 Drug List Change Notification (Commercial)

June 18, 2025

Updates on Existing Criteria

August 2025. The following changes to criteria are effective August 22, 2025:

Prior Authorization Criteria – Clinical Updates

Alosetron – remove Lotronex from affected medications
Anti-tuberculosis Agents – remove policy
Besremi – update covered uses, required medical information, and appropriate treatment regimen
Botox – update appropriate treatment regimen and exclusion criteria
Dupilumab – update required medical information, appropriate treatment regimen, and age restriction
Eplontersen, Patisiran, Vutrisiran – update covered uses, required medical information, appropriate treatment regimen, and exclusion criteria
Evolocumab – update required medical information
FDA Approved Drug – Drug or Indication Not Yet Reviewed By Plan for Formulary Placement – update prescriber
Fluocinolone Ocular Implant – update required medical information and appropriate treatment regimen
Inebilizumab-cdon – update covered uses, required medical information, appropriate treatment regimen, and prescriber
Neonatal FC Receptor Antagonists – add Vyvgart Hytrulo PFS and Imaavy to affected medications and update covered uses, appropriate treatment regimen, and age restriction
Non-preferred medical drug codes – update appropriate treatment regimen
Oncology Agents – add Unloxcyt, Avmapki - Fakzynja Co-Pak, and Ensacove to affected medications
Osilodrostat – update appropriate treatment regimen
Pegasys – update covered uses, required medical information, appropriate treatment regimen, exclusion criteria, age restriction, prescriber, and coverage duration
Prolia – update policy name to “Denosumab”
Proximal Compliment Inhibitor - update covered uses, required medical information, and appropriate treatment regimen
Reslizumab – update appropriate treatment regimen
Sparsentan – update policy name to “ETA Receptor Antagonists,” add Vanrafia to affected medications
Spravato – update required medical information
Targeted Immune Modulators – update affected medications for Giant Cell Arteritis (GCA) and Cytokine Release Syndrome (CRS)
Tedizolid – update appropriate treatment regimen and age restriction
Tirzepatide – update required medical information, appropriate treatment regimen, and exclusion criteria
Xgeva – add Wyost to affected medications
Zinplava – remove policy

Preferred Drug List (PDL) Changes

August 2025. The following changes to the drug list are effective August 22, 2025:

Formulary Additions

Sunlenca 300 mg tablet add tier 3 with SP, quantity limit, and prior authorization
Abirtega tablet add tier 3 with SP, partial fill, and medical necessity prior authorization
Ustekinumab injection add tier 3 with SP and medical necessity prior authorization
Ticagrelor tablet add tier 1 with medical necessity prior authorization
Umeclidinium bromide / Vilanterol inhalation add tier 1 with medical necessity prior authorization
Vykat XR tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Ensacove capsule add tier 3 with SP, quantity limit, and prior authorization
Ctexli tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Vanrafia tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Qfitlia injection add tier 3 with SP, limited access, quantity limit, and medical necessity prior authorization
Avmapki– Fakzynja Co-Pack capsule and tablet add tier 3 with SP, limited access, and prior authorization
Neffy nasal spray add tier 3 with quantity over time limit
Vyvgart Hytrulo PFS injection add tier 3 with SP, quantity limit, and prior authorization
Livmarli tablet add tier 3 with SP, limited access, and prior authorization
Xpovio 10 mg tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Arbli solution add tier 3 with quantity limit and medical necessity prior authorization
Hemiclor solution add tier 3 with quantity limit and medical necessity prior authorization
Jubbonti injection add tier 3 with SP and medical necessity prior authorization
Wyost injection add tier 3 with SP and medical necessity prior authorization
Symbravo tablet add tier 3 with quantity limit and medical necessity prior authorization
Tezruly solution add tier 3 with quantity limit and medical necessity prior authorization
Edurant PED solution add tier 3 with medical necessity prior authorization

Prior Authorization

Remove Prior Authorization
- Sirturo tablet
- Pretomanid tablet
Add Medical Necessity
- Emend capsule and solution
- Lotronex tablet

Removed from Formulary

Coumadin tablet
Qvar inhalation 40 mcg/actuation and 8 mcg/actuation
Fentanyl citrate lozenge on a handle
Zostavax injection
Varubi 90 mg tablet
Aloxi injection
A-Hydrocort injection 100 mg
A-Methapred injection 40 mg and 125 mg
Catapres tablet
Levaquin tablet and solution
Tarka tablet
Muse pellet
Kadian extended release capsule

Quantity Limit

Update
- Sublocade 300 mg/1.5 mL injection

Add to Specialty Pharmacy

Vemlidy tablet

Removed from Limited Access

Miglustat capsule

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

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