Updates on Existing Criteria
June 2026. The following changes to criteria are effective by June 22, 2026:
Prior Authorization Criteria – Clinical Updates
- Adbry – remove standalone policy (see Targeted Immune Modulators policy)
- Denosumab – update affected medications
- Enzyme Replacement Therapy (ERT) For Gaucher Disease Type 1 – update covered uses and required medical information
- Immune Globulin – update affected medications
- Inebilizumab-cdon – update covered uses, required medical information, appropriate treatment, and prescriber restrictions
- Lotilaner – retire standalone policy (see Medical Necessity policy)
- Medical Necessity – update affected medications
- Non-Preferred Medical Drug Codes – update affected medications and appropriate treatment
- Oncology agents – new policy replaces old policy with same name
- Opzelura – remove standalone policy (see Topical Skin Disease Agents policy)
- Palynziq – update covered uses and age restriction
- Phesgo – remove standalone policy (see Oncology Agents policy)
- Rituximab – new policy replaces old policy with same name
- Subcutaneous Immune Globulin – update affected medications and covered uses
- Targeted Immune Modulators – update indication-specific criteria
- Trastuzumab – remove standalone policy (see Oncology Agents policy)
- Xgeva – update affected medications
Preferred Drug List (PDL) Changes
June 2026. The following changes to the drug list are effective June 22, 2026:
Formulary Additions
- Aukelso injection add tier 3 with SP and prior authorization
- Desmoda solution add tier 3 with medical necessity prior authorization
- Loargys injection add tier 3 with SP, limited access, and prior authorization
- Myqorzo solution add tier 3 with SP, quantity limit, and medical necessity prior authorization
- Ontralfy solution add tier 3 with quantity limit and medical necessity prior authorization
- Orladeyo pellets add tier 3 with SP, limited access, quantity limit, and prior authorization
- Rezenopy nasal spray add tier 2 with quantity limit
- Rizafilm film add tier 3 with quantity limit
- Sdamlo solution add tier 3 with medical necessity prior authorization
- Shingrix injection add tier 0
- Sogroya injection add tier 3 with SP and prior authorization
- Vibrique film add tier 3 with medical necessity prior authorization
- Vraylar 0.75 mg capsule add with tier 3, quantity limit, and step therapy
- Wegovy tablet add tier 3 with quantity limit and medical necessity prior authorization
- Yuvezzi solution add tier 3 with quantity limit and medical necessity prior authorization
- Yuviwel kit add tier 3 with SP, limited access, and medical necessity prior authorization
- Zepbound Kwikpen solution add tier 3 with quantity limit and medical necessity prior authorization
- Zycubo solution add tier 3 with SP, limited access, quantity limit, and prior authorization
Update Quantity Limit
- Opzelura cream
Add Medical Necessity
- Lotilaner solution
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
June 2026. The following changes to the drug list are effective June 22, 2026:
Formulary Additions
- Orladeyo pellets add tier 4 with SP, limited access, quantity limit, and prior authorization
- Shingrix injection add tier 0
- Sogroya injection add tier 4 with SP and prior authorization
- Vraylar 0.75 mg capsule add with tier 3, quantity limit, and step therapy
Update Quantity Limit
- Opzelura cream
Remove from Formulary
- Lotilaner solution; consider ivermectin tablet and ivermectin cream
- Xgeva, Wyost, Osenvelt, Bomnytra, and Bilprevda solutions (continues to be covered on medical benefit with prior authorization); consider zolderonic acid injection, pamidronate injection, alendronate tablet, risdedronate tablet, and ibandronate tablet.
See the PacificSource Drug Lists page for the current drug list.