December 2025 Drug List Change Notification (Commercial)

October 20, 2025

Updates on Existing Criteria

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

Prior Authorization Criteria – Clinical Updates

Hereditary Angioedema – update covered uses, appropriate treatment, and exclusion criteria
Inclisiran – update appropriate treatment
Finerenone – update covered uses, required medical information, and appropriate treatment
Proximal Complement Inhibitor – update covered uses, required medical information, appropriate treatment, and age restriction
Avatrombopag – update covered uses, appropriate treatment, and age restriction
Resmetirom – update appropriate treatment
Anti-Amyloid Monoclonal Antibody – update affected medications and covered uses
Bevacizumab – update appropriate treatment
Evolocumab – update covered uses, required medical information, and appropriate treatment
Concizumab – update covered uses, required medical information, and appropriate treatment
MEK Inhibitors For Neurofibromatosis Type 1 (NF1) – update covered uses and age restriction
Targeted Immune Modulators – update quantity limitations
Romosozumab – update covered uses
Intravitreal Complement Inhibitors – update required medical information and appropriate treatment
Posaconazole – replace existing policy with new policy
Isavuconazonium Sulfate – update covered uses, required medical information, appropriate treatment, and coverage duration
Tirzepatide – update required medical information
Oteseconazole – update appropriate treatment
Pemivibart – update covered uses, required medical information, appropriate treatment, and exclusion criteria
Givinostat – update exclusion criteria
Ravicti – update appropriate treatment
Opzelura – update appropriate treatment, exclusion criteria, age restriction, and coverage duration
Journavx – remove from prior authorization policy and place into new step therapy policy
Hormone Supplementation Under 18 Years of Age – remove policy
Intravitreal Anti-VEGF Therapy – update appropriate treatment
Eltrombopag Derivatives – update affected medications, appropriate treatment, and age restriction

Preferred Drug List (PDL) Changes

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

Formulary Additions

mNexspike vaccine add Tier 3 and medical necessity prior authorization
Anzupgo cream add Tier 3 and medical necessity prior authorization
Vizz solution add Tier 3 and medical necessity prior authorization
Dawnzera injection add Tier 3 with SP, quantity limit, and prior authorization
Zegrovy tablet add Tier 3 with SP, quantity limit, and prior authorization
Hernexeos tablet add Tier 3 with SP, quantity limit, limited access, and prior authorization
Sephience powder add Tier 3 with SP, limited access, and medical necessity prior authorization
Brinsupri tablet add Tier 3 with SP, quantity limit, limited access, and medical necessity prior authorization
Brekiya injection add Tier 3 with medical necessity prior authorization
Wayrilz tablet add Tier 3 with SP, quantity limit, limited access, and prior authorization
Modeyso capsule add Tier 3 with SP, quantity limit, limited access, and prior authorization
Blujepa capsule add Tier 3 with quantity limit and medical necessity prior authorization
Kerendia 40 mg tablet add Tier 3 with quantity limit and prior authorization
Spevigo 300 mg/2 mL syringe add Tier 3 with SP, quantity limit and medical necessity prior authorization
Egrifta WR injection add Tier 3 with SP and medical necessity prior authorization
Kirsty solution add Tier 3 with medical necessity prior authorization
Doptelet Sprinkle tablet add Tier 3 with SP, quantity limit, and prior authorization
Brynovin solution add Tier 2 with medical necessity prior authorization
Zurnai injection add Tier 2 with quantity limit
Leqembi Iqlik injection add Tier 3 with prior authorization
Brukinsa tablet add Tier 3 with SP, quantity limit, limited access, and prior authorization
Perampanel tablet add Tier 1
Dexcom G7 15 Day sensor add Tier 2 with quantity limit and prior authorization
Truqap Therapy Pack add Tier 3 with SP, quantity limit, limited access, and prior authorization
Eltrombopag tablet and packet add Tier 3 with SP, quantity limit, and prior authorization
Fidaxomicin tablet add Tier 1 with quantity limit
Accu-Chek Guide, Aviva Plus, and Smartview test strips add tier 2 with quantity limit
Accu-Chek Guide Care and Guide Me Care meter kit add tier 2

Prior Authorization

Remove Prior Authorization
- Journavx capsule
- Depo-Estradiol injection
- Dotti patch
- Elestrin gel
- Estradiol gel, patch, and tablet
- Estradiol valerate oil
- Estrogel gel
- Evamist solution
- Lyllana patch
- Menest tablet
- Menostar patch
- Methyltestosterone capsule
- Premarin tablet
- Testosterone cypionate solution
- Testosterone enanthate solution
- Testosterone gel and solution
Add Medical Necessity
- mNexspike vaccine
- Anzupgo cream
- Vizz solution
- Sephience powder
- Brinsupri tablet
- Blujepa capsule
- Spevigo 300 mg/2 mL syringe
- Egrifta WR injection
- Kirsty solution
- Brynovin solution
- Fycompa tablet and suspension
- Dificid tablet
- Promacta tablet and packet

Removed from Formulary

Egrifta injection
Androderm patch
OneTouch Verio, Ultra, and Ultra Blue test strips; consider Accu-check Chek Guide, Aviva Plus, and Smartview strips
Onetouch Ultra 2 kit with device; consider Accu-Chek Guide Care and Guide Me Care meter kit

Step Therapy

Add
- Journavx capsule

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

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