Updates on Existing Criteria
May 2026. The following changes to criteria are effective by May 22, 2026:
Prior Authorization Criteria – Clinical Updates
- Addyi – update covered uses
- Anti-Herpetic Agents – update affected drugs in step therapy policy
- Cablivi – update covered uses
- Calcitonin Gene-Related Peptide (CGRP) Inhibitors – update to new policy with same name (posted during previous update)
- Continuous Glucose Monitors – update to new policy with same name (posted during previous update)
- ETA Receptor Antagonists – update required medical information, appropriate treatment, exclusion criteria
- Fibrates – retire policy (affected drug discontinued)
- Megestrol – update affected drugs in step therapy policy
- Mitapivat – update covered uses, required medical information, appropriate treatment, exclusion
- Nusinersen – update exclusion criteria
- Omidubicel – update required medical information, appropriate treatment, age restriction, prescriber
- Oncology Agents – update affected medications
- Proximal Complement Inhibitor – update required medical information, appropriate treatment, exclusion criteria
- Risdiplam – update exclusion criteria
- Targeted Immune Modulators – update to new policy with same name (posted during previous update)
Preferred Drug List (PDL) Changes
May 2026. The following changes to the drug list are effective May 22, 2026:
Formulary Additions
- Aqvesme tablet add tier 3, SP, limited access, quantity limit, and prior authorization
- Cardamyst solution add tier 3 with quantity over time limit and prior authorization
- Cladribine tablet add tier 3 with SP, quantity limit, and prior authorization
- Exdensur solution add tier 3 with SP, limited access, quantity over time limit, and medical necessity prior authorization
- Furoscix solution add tier 3 with medical necessity prior authorization
- Hyrnuo tablet add tier 3 with SP, quantity limit, and prior authorization
- Lasix ONYU cartridge add tier 3 with quantity limit and medical necessity prior authorization
- Omlonti solution add tier 3 with medical necessity prior authorization
- Pivya tablet add tier 3 with quantity over time limit and medical necessity prior
- Voyxact solution add tier 3 with SP, quantity limit, limited access, and prior authorization
- Vraylar capsule add tier 3 with quantity limit and step therapy
Update Quantity Limit
- Blujepa
Remove from Formulary
- Acyclovir solution 500 mg
- Megace ES suspension
- Sitavig tablet
- Triglide tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
May 2026. The following changes to the drug list are effective May 22, 2026:
Formulary Additions
- Aqvesme tablet add tier 4, SP, limited access, quantity limit, and prior authorization
- Cladribine tablet add tier 4 with SP, quantity limit, and prior authorization
- Hyrnuo tablet add tier 4 with SP, quantity limit, and prior authorization
- Voyxact solution add tier 3 with SP, quantity limit, limited access, and prior authorization
- Vraylar capsule 0.5 mg and 0.7g mg add tier 3 with quantity limit and step therapy
See the PacificSource Drug Lists page for the current drug list.