December 2026 Drug List Change Notification (Commercial)

October 22, 2026

Updates on Existing Criteria

December 2026. The following changes to criteria are effective by December 22, 2026:

Prior Authorization Criteria – Clinical Updates

BCR-ABL Tyrosine Kinase Inhibitors – Second Generation – update affected medications and appropriate treatment
Formulary Exception Criteria – Zepbound – update required medical information, appropriate treatment, and exclusion criteria
Glucagon-like Peptide (GLP1-1) Receptor Agonist Policy Update – update required medical information, appropriate treatment, and exclusion criteria
Intravitreal Anti-VEGF Therapy – update covered uses and required medical information
Medical Necessity – update affected medications
Medical Necessity – Zepbound - update required medical information, appropriate treatment, and exclusion criteria
Neonatal FC Receptor Antagonists – update covered uses, required medical information, appropriate treatment, exclusion criteria, and prescriber restrictions
Oncology Agents – update affected medications
Proximal Complement Inhibitor – update covered uses and required medical information
Pulmonary Hypertension Agents – replace the following policies that are being removed: Sotatercept-CSRK, Epoprostenol, Tyvaso, Phosphodiesterase-5 (PDE-5) Enzyme Inhibitors for Pulmonary Arterial Hypertension, Remodulin, Orenitram, Endothelin Receptor Antagonists, Riociguat
Targeted Immune Modulators – update the HES section
Weight Loss Prior Authorization Criteria for Select Large Groups – update affected drugs

Preferred Drug List (PDL) Changes

December 2026. The following changes to the drug list are effective December 22, 2026:

Formulary Additions

Adquey ointment add tier 3, quantity limit, and medical necessity prior authorization
Beqalzi tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Bixlenvo tablet add tier 2 with SP, quantity limit
Brivaracetam oral solution add tier 1 with quantity limit
Brivaracetam tablets add tier 1 with quantity limit
Bucapsol 5 mg capsule add tier 3 with quantity limit and medical necessity prior authorization
Buspirone 5 mg capsule add tier 1
Cavhanza tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Clotic otic solution add tier 3 with medical necessity prior authorization
Etcamah tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Gwyn Lo transdermal patch add tier 0
Jideytro tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Langlara pen add tier 3 with medical necessity prior authorization
Lipfendra add tier 3 with quantity limit and medical necessity prior authorization
Lisraya tablet add tier 3 with SP, limited access, quantity limit, and medical necessity prior authorization
mFlusiva injection add tier 0
Milnacipran tablet add tier 1 with step therapy and quantity limit
Mimrylo injection add tier 3 with SP, limited access, and prior authorization
Nuzolvence suspension add tier 3, quantity over time limit, and medical necessity prior authorization
Omlyclo injection add tier 3 with quantity limit and medical necessity prior authorization
Rasonque tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Zenbexus capsule add tier 3 with SP, quantity limit, and prior authorization

Medical Necessity

Add Medical Necessity
- Corlanor tablet and solution
- Revlimid capsule
- Savella tablet
Remove Medical Necessity
- Yutrepia powder

Tier update

Breztri aerosol

Remove prior authorization

Breztri aerosol

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

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