Updates on Existing Criteria
August 2026. The following changes to criteria are effective by August 22, 2026:
Prior Authorization Criteria – Clinical Updates
- CFTR Modulators – update covered uses and age restriction
- ETA Receptor Antagonists – Update covered uses, required medical information, appropriate treatment, and exclusion criteria
- Evkeeza and Juxtapid – update age restriction
- Evolocumab – update required medical information and appropriate treatment
- Hereditary Angioedema – update appropriate treatment and coverage duration
- Inclisiran – update required medical information and appropriate treatment
- Medical Necessity – update affected medications
- Oncology Agents – update affected medications
- Sotatercept-CSRK – update required medical information
- Tzield – update required medical information and age restriction
Preferred Drug List (PDL) Changes
August 2026. The following changes to the drug list are effective August 22, 2026:
Formulary Additions
- Arynta oral solution add tier 3 with medical necessity prior authorization
- Atmeski suspension add tier 3 with medical necessity prior authorization
- Auvelity tablet titration pack add tier 3 with quantity limit and medical necessity prior authorization
- Breztri Aerosphere inhaler add tier 3, quantity limit and medical necessity prior authorization
- Foundayo tablet add tier 3 with quantity limit and medical necessity prior authorization
- Icotyde tablet add tier 3 with quantity limit and medical necessity prior authorization
- Idvynso tablet add tier 2 with quantity limit
- Jakafi XR tablet add tier 3 with SP, quantity limit, and prior authorization
- Juxtapid capsule add tier 3 with SP, limited access, and prior authorization
- Kygevvi powder add tier 3 with SP, limited access, quantity limit, and medical necessity prior authorization
- Lerechol solution add tier 3 with quantity limit and medical necessity prior authorization
- Lyforli capsule add tier 3 with SP and prior authorization
- Methocarbamol tablet 1000 mg add tier 3 with medical necessity prior authorization
- Nereus capsule add tier 3 with medical necessity prior authorization
- Nintedanib capsule add tier 3 with SP, limited access, quantity limit, and prior authorization
- Relgaabi capsule add tier 3 with quantity limit and medical necessity prior authorization
- Saphnelo prefilled syringe add tier 3 with SP, quantity limit and medical necessity prior authorization
- Wainua prefilled syringe add tier 3 with SP, limited access, quantity limit, and prior authorization
- Wegovy HD injection add tier 3 with quantity limit and medical necessity prior authorization
- Widaplik tablet add tier 3 with quantity limit
- Zolymbus gel add tier 3 with quantity limit and medical necessity prior authorization
Medical Necessity
- Remove Medical Necessity
- Dapagliflozin tablet
- Dapagliflozin-metformin ER tablet
- Add Medical Necessity
- Farxiga tablet
- Ofev capsule
- Xigduo XR tablet
Remove from formulary
- Ocaliva tablet (discontinued)
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
August 2026. The following changes to the drug list are effective August 22, 2026:
Formulary Additions
- Idvynso tablet add tier 2 with quantity limit
- Jakafi XR tablet add tier 3 with SP, quantity limit, and prior authorization
- Lyforli capsule add tier 3 with SP and prior authorization
- Nintedanib capsule add tier 4 with SP, limited access, quantity limit, and prior authorization
- Wainua prefilled syringe add tier 3 with SP, limited access, quantity limit, and prior authorization
Remove Medical Necessity
- Dapagliflozin tablet
- Dapagliflozin-metformin ER tablet
Remove from Formulary
- Farxiga tablet; consider generic dapagliflozin tablet
- Ocaliva tablet (discontinued)
- Ofev capsule; consider generic nintedanib capsule
- Prolia, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv injections; covered on medical formulary, consider zoledronic acid, pamidronate, alendronate, risedronate, ibandronate
- Xigduo XR tablet; consider generic dapagliflozin-metformin ER tablet
See the PacificSource Drug Lists page for the current drug list.