July 2025 Drug List Change Notification (Commercial)

Updates on Existing Criteria

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

Prior Authorization Criteria – Clinical Updates

• Targeted Immune Modulators –update preferred pharmacy drugs for Crohn’s Disease to include Tremfya 
   

Preferred Drug List (PDL) Changes

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

Formulary Additions

• Tremfya Crohn’s induction injection 200 mg/2mL and 100 mg/mL injection add tier 3 with SP, quantity limit, and prior authorization
   

Prior Authorization

• Remove Medical Necessity
  • Dexlansoprazole capsule
     

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

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

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

Formulary Additions

• Tremfya Crohn’s induction injection 200 mg/2mL and 100 mg/mL injection add tier 4 with SP, quantity limit, and prior authorization
• Xultophy injection add tier 3 with medical necessity prior authorization 
   

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