Updates on Existing Criteria
October 2025. The following changes to criteria are effective October 1, 2025:
Removed from Formulary
Androderm patch
Prior Authorization
- Remove Prior Authorization
- Depo-Estradiol oil
- Estradiol twice weekly patch
- Estradiol weekly patch
- Dotti patch
- Estradiol tablet
- Estradiol gel
- Menest tablet
- Elestrin gel
- Estrogel gel
- Evamist solution
- Premarin tablets
- Testosterone cypionate solution
- Testosterone enanthate solution
- Testosterone gel
- Testosterone patch
- Climara patch
- Estrace tablets
- Estradiol valerate oil
- Lyllana patch
- Menostar patch
- Methyltestosterone capsule
- Minivelle patch
- Premarin solution
- Vivelle-dot patch
- Alvesco inhalation
- Breztri inhalation
- Bronchitol capsule
- Zileuton extended release tablet
- Apidra solution
- Basaglar KwikPen solution
- Humulin 70/30 and 70/30 KwikPen solution
- Insulin Degludec and Degludec FlexTouch solution
- Insulin Glargine and GlargineSolostar solution
- Insulin Glargine-yfgn solution
- Novolin 70/30 ReliOn and Flexpen Relion solution
- Semglee solution
- Xultophy solution
- Alosetron tablet
- Alosetron tablet
- Dapagliflozin pro-metformin extended-release tablet
- Dapagliflozin propanediol tablet
- Deflazacort tablet and suspension
- Diclofenac potassium (migraine) packet
- Dihydroergotamine mesylate solution
- Flucytosine capsule
- Isosorb dinitrate-hydralazine tablet
- Ivabradine tablet
- Metoclopramide tablet
- Naproxen-esomeprazole magnesium delayed release tablet
- Nilutamide tablet
- Ofloxacin tablet
- Orphenadrine-acetaminophen-caffeine tablet
- Paromomycin sulfate capsule
- Penicillamine capsule
- Phenoxybenzamine capsule
- Posaconazole suspension
- Posaconazole suspension and delayed release tablet
- Pyrimethamine tablet
- Rufinamide suspension
- Rufinamide tablet
- Rufinamide tablet
- Sodium phenylbutyrate powder
- Sumatriptan-naproxen sodium tablet
- Tadalafil tablet
- Trientine capsule
- Voriconazole suspension
Remove Step Therapy
- Acyclovir cream
- Brimonidine gel
- Dutasteride-Tamsulosin capsule
- Fenoprofen capsule
- Fesoterodine tablet
- Fluoxetine capsule delayed release 90 mg
- Frovatriptan tabket
- Gabapentin tablet
- Glutamine (Sickle Cell) powder
- Megestrol acetate suspension 625 mg/5mL
- Mirabegron tablet
- Penciclovir cream
- Zolmitriptan nasal spray
See the PacificSource Drug Lists page for the current drug list.