Updates on Existing Criteria
April 2026. The following changes to criteria are effective by April 9, 2026:
Prior Authorization Criteria – Clinical Updates
- Glucagon-Like Peptide (GLP-1) Receptor Agonist – updated covered uses, required medical information, appropriate treatment, and exclusion criteria
- Medical Necessity – updated exclusion criteria
- Commercial Formulary Exception Criteria – updated exception criteria and added the policy Formulary Exception Criteria – Nurtec
Preferred Drug List (PDL) Changes
April 2026. The following changes to the drug list are effective April 9, 2026:
Formulary Additions
- Tofidence subcutaneous solution add tier 3 with SP, quantity limit, and medical necessity prior authorization
Update Quantity Limit
- Journavx
- Nurtec
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
April 2026. The following changes to the drug list are effective April 9, 2026:
Update Quantity Limit
- Journavx
Formulary Exception Criteria
- Add Policy for Non-Formulary Drug
- Tirzepatide injection (policy name: Formulary Exception Criteria – Nurtec)
See the PacificSource Drug Lists page for the current drug list.