February 2026 Drug List Change Notification (Commercial)

Updates on Existing Criteria

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

Prior Authorization Criteria – Clinical Updates

• Botox – update coverage duration (will be published by January 22^nd, 2026)
• Calcitonin Gene-Related Peptide (CGRP) Inhibitors – update covered uses and appropriate treatment for Ubrelvy (will be published by January 22^nd, 2026)
• Continuous Glucose Monitors – update affected products 
• Deflazacort – update coverage duration (will be published by January 22^nd, 2026)
• Denosumab – update affected agents 
• Dupilumab – update required medical information
• Erythropoiesis Stimulating Agents (ESAs) – update appropriate treatment regimen (will be published by January 22^nd, 2026)
• Evkeeza – update age restriction 
• Formulary Exception Criteria - Wegovy – create new policy
• Glucagon-Like Peptide (GLP-1) Receptor Agonist – update required medical information and appropriate treatment 
• Growth Hormones – update appropriate treatment regimen (will be published by January 22^nd, 2026)
• Histrelin – update required medical information and prescriber (will be published January 22^nd, 2026)
• Immune globulin – update affected medications
• Leuprolide – update required medical information and prescriber (will be published January 22^nd, 2026)
• Medical Necessity - Wegovy  – create new policy
• Natalizumab - update required medical information 
• Oncology Agents – update affected medications
• Sphingosine 1-Phosphate (S1P) Receptor Modulators – update covered uses and appropriate treatment 
• Subcutaneous immune globulin – update covered uses, appropriate treatment, prescriber, and coverage duration
• Targeted Immune Modulators – update affected medications, renewal criteria, quantity limits
• Testosterone – update required medical information, appropriate treatment, and prescriber (will be published January 22^nd, 2026)
• Tezspire – update covered uses, required medical information, appropriate treatment, and age restriction
• Tirzepatide – remove policy, replace with the following policies: Medical Necessity - Tirzepatide and Formulary Exception Criteria - Tirzepatide
• Topical dermatitis and psoriatic agents – update covered uses, appropriate treatment, and age restriction (will be published January 22^nd, 2026)
• Triptorelin – update required medical information and prescriber (will be published January 22^nd, 2026)
• Vyjuvek – update appropriate treatment and age restriction 
• Xgeva – update affected medications
• Xolair – update appropriate treatment regimen 

Preferred Drug List (PDL) Changes

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

Formulary Additions

• Adalimumab-aacf solution add tier 3 with SP, quantity limit, and medical necessity prior authorization
• Adalimumab-aaty solution add tier 3 with SP, quantity limit, and medical necessity prior authorization
• Bildyos solution add tier 3 with SP and prior authorization
• Bilprevda solution add tier 3 with SP and prior authorization
• Bynfezia pen add tier 3 with medical necessity prior authorization
• Eliquis solution add tier 3 with medical necessity prior authorization
• Enbumyst nasal spray add tier 3 with quantity limit, and medical necessity prior authorization
• Escitalopram capsule add tier 3 with quantity limit 
• Exxua tablet add tier 3 with quantity limit, and medical necessity prior authorization
• Forzinity injection add tier 3 with SP, limited access, quantity limit, and prior authorization
• Inluriyo tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
• Jascayd tablet add tier 3 with SP, quantity limit, and medical necessity prior authorization
• Lopressor solution add tier 3 with medical necessity prior authorization
• Lynkuet capsule add tier 3 with quantity limit, and medical necessity prior authorization
• Olpruva suspension add tier 3 with SP and medical necessity prior authorization
• Ospomyv solution add tier 3 with SP and prior authorization
• Otezla XR tablet add tier 3 with SP, quantity limit, and prior authorization
• Palsonify tablet add tier 3 with SP, limited access, quantity limit, and medical necessity prior authorization
• Phyrago tablet add tier 3 with SP, quantity limit, and medical necessity prior authorization
• Prucalopride tablet add tier 1 with quantity limit 
• Rhapsido tablet add tier 3 with SP, quantity limit, and medical necessity prior authorization
• Starjemza solution add tier 3 with SP, limited access, and medical necessity prior authorization
• Subvenite solution add tier 3 with quantity limit and medical necessity prior authorization
• Tonmya tablet add tier 3 with quantity limit and medical necessity prior authorization
• Tyenne subcutaneous solution add tier 3 with SP, quantity limit, and medical necessity prior authorization
• Tyruko injection add tier 3 with SP and medical necessity prior authorization
• Vyscoxa suspension add tier 3 with quantity limit and medical necessity prior authorization
• Xarelto starter pack add tier 2 with quantity limit 
• Zoryve 0.05% cream add tier 3 with quantity limit and prior authorization

Prior Authorization

• Remove Prior Authorization
  • Sunlenca tablet
     
• Remove Medical Necessity
  • Qelbree capsule
  • Ubrelvy tablet (add to CGRP Inhibitors policy)
  • Velsipity tablet (add to S1P Receptor Modulators policy)
     
• Update to Prior Authorization – New Start Only
  • Dasatinib tablet
  • Erleada tablet
  • Lenalidomide tablet
  • Nilutamide tablet 
  • Nubeqa tablet
  • Trikafta tablet
  • Xtandi tablet

Remove Quantity Limit

• Amphetamine-dextroamphetamine ER capsule 20mg, 25mg, 30mg 

Remove from Formulary

• Accu-Chek Guide Care and Guide Me Care meter kit; please see instructions on our website on how to receive a free meter from the manufacturer 
• Nature-Throid tablet
• Reyvow tablet 
• WP Thyroid tablet

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

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

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

Formulary Additions

• Bildyos solution add tier 3 with SP and prior authorization
• Bilprevda solution add tier 3 with SP and prior authorization
• Forzinity injection add tier 3 with SP, limited access, quantity limit, and prior authorization
• Inluriyo tablet add tier 4 with SP, limited access, quantity limit, and prior authorization
• Ospomyv solution add tier 3 with SP and prior authorization
• Otezla XR tablet add tier 3 with SP, quantity limit, and prior authorization
• Prucalopride add tier 1 with quantity limit 
• Qelbree capsule add tier 3 with quantity limit
• Ubrelvy tablet add tier 4 with quantity limit and prior authorization 
• Velsipity tablet add tier 4 with SP, quantity limit, and prior authorization
• Veozah tablet add tier 3 with quantity limit and medical necessity prior authorization
• Xarelto starter pack add tier 2 with quantity limit 
• Zoryve 0.05% cream add tier 3 with quantity limit and prior authorization

Prior Authorization

• Remove Prior Authorization
  • Sunlenca tablet
     
• Update to Prior Authorization – New Start Only
  • Dasatinib tablet
  • Erleada tablet
  • Lenalidomide tablet
  • Nilutamide tablet 
  • Nubeqa tablet
  • Trikafta tablet
  • Xtandi tablet

Quantity Limit

• Remove Quantity Limit
  • Amphetamine-dextroamphetamine ER capsule 20mg, 25mg, and 30mg 
     
• Update Quantity Limit
  • Avonex pen auto-injector kit 30 mcg/0.5 mL intramuscular

Remove from Formulary

• Accu-Chek Guide Care and Guide Me Care meter kit; please see instructions on our website on how to receive a free meter from the manufacturer 
• Alosetron tablet (Montana only); consider loperamide, dicyclomine, hyoscyamine, amitriptyline, nortriptyline
• Deflazacort tablet and suspension (Montana only); consider Agamree
• Diclofenac potassium packet (Montana only); consider alfuzosin, doxazosin, silodosin, finasteride, tamsulosin, terazosin
• Dihydroergotamine mesylate nasal solution and injection (Montana only); consider almotriptan, eletriptan, naratriptan, sumatriptan, rizatriptan, rizatriptan oraldisintegrating tablet (ODT), zolmitriptan, zolmitriptan ODT, frovatriptan, zolmitriptan nasal, Ubrelvy
• Isosorbide Dinitrate-Hydralazine tablet (Montana only); consider isosorbide dinitrate tablet, hydralazine tablet
• Metoclopramide tablet dispersible (Montana only); consider metoclopramide tablet 
• Naproxen-Esomeprazole Mg Delayed Release tablet (Montana only); consider naproxen tablet, esomeprazole capsule
• Nature-Throid tablet
• Reyvow tablet 
• Tadalafil tablet (Montana only); consider alfuzosin, doxazosin, silodosin, finasteride, tamsulosin, terazosin
• WP Thyroid tablet

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