Updates on Existing Criteria
October 2025. The following changes to criteria are effective October 22, 2025:
Prior Authorization Criteria – Clinical Updates
- Antihemophilic factors – update age restriction
- Botox – update exclusion criteria
- Cantharidin – update policy name to Molluscum Contagiosum Agents, add Zelsuvmi to affected medications, and update appropriate treatment regimen and age restriction
- Dasatinib – remove policy and add affected medication(s) to new policy BCR-ABL Tyrosine Kinase Inhibitors- Second generation
- Denosumab – add Stoboclo and Conexxence to affected medications
- Dinutuximab – remove policy
- Dupilumab – update covered uses, required medical information, appropriate treatment regimen, and age restriction
- Eflornithine – remove policy
- Emapalumab – update covered uses, required medical information, and appropriate treatment regimen
- Hepatitis C Direct Acting Antiviral – update required medical information and coverage duration
- Hereditary Angioedema – add Andembry and Ekterly to affected medications, update covered uses, appropriate treatment, and exclusion criteria
- Hereditary Tyrosinemia (HT-1) Agents – update policy name to Nitisinone, update affected medications, covered uses, required medical information and appropriate treatment regimen
- Intravitreal Anti-VEGF Therapy – update covered uses and appropriate treatment regimen
- Medical Necessity – remove Jubbonti and Wyost from affected medications, update other affected medications
- Mepolizumab – update covered uses, required medical information, appropriate treatment regimen, age restriction, and prescriber
- Myeloid growth factors – add Ryzneuta to affected medications and update covered uses and appropriate treatment
- Naxitamab – remove policy
- Nilotinib – remove policy and add affected medication(s) to new policy BCR-ABL Tyrosine Kinase Inhibitors- Second generation
- Oncology Agents – add Emrelis, Lynozyfic, Unituxin, Iwilfin, Danyelza, and Ibtrozi to affected medications, remove Bosulif and Danziten from affected medications
- Osilodrostat – update required medical information and appropriate treatment
- Targeted Immune Modulators – add Imuldosa to affected medications
- Topical Dermatitis and Psoriatic Agents – update covered uses, appropriate treatment regimen, and age restriction
- Xgeva – add Osenvelt and Bomnytra to affected medications
Preferred Drug List (PDL) Changes
October 2025. The following changes to the drug list are effective October 22, 2025:
Formulary Additions
- Andembry injection add tier 3 with SP, quantity limit, and prior authorization
- Averi topical kit add tier 0
- Bomyntra injection add tier 3 with SP and prior authorization
- Bucapsol capsules add tier 3 with quantity limit, and medical necessity prior authorization
- Conexxence injection add tier 3 with SP and prior authorization
- Ekterly tablet add tier 3 with SP, limited access, quantity versus time limit, and prior authorization
- eslicarbazepine acetate tablet add tier 1 with quantity limit
- Harliku tablet add tier 3 with SP, quantity limit, limited access, and medical necessity prior authorization
- Ibtrozi capsule add tier 3 with SP, limited access, quantity limit, and prior authorization
- Imuldosa injection add to tier 3 with SP, limited access, and medical necessity prior authorization
- Khindivi solution add tier 3 with quantity limit and medical necessity prior authorization
- Merilog add to tier 3 with medical necessity prior authorization
- Nilotinib D-Tartrate capsules add tier 3 with SP, quantity limit, and medical necessity prior authorization
- Orlynvah tablet add tier 3 with quantity limit and prior authorization
- Osenvelt injection add tier 3 with SP and prior authorization
- Rivaroxaban tablet and suspension add tier 1 with quantity limit
- Ryzneuta injection add tier 3 with SP and prior authorization
- Sacubitril/valsartan tablet add tier 1 with quantity limit
- Stoboclo injection add tier 3 with SP and prior authorization
- Tryptyr solution add tier 3 with quantity limit and medical necessity prior authorization
- Tybost add tier 2 with quantity limit
- Tybost tablet add tier 2
- Yeztugo tablet and injection add tier 0
- Yutrepia capsules add tier 3 with SP, quantity limit, and medical necessity prior authorization
- Zelsuvmi gel add tier 3 with quantity limit and prior authorization
- Zevaskyn gene therapy add tier 3 with SP and prior authorization
Prior Authorization
- Add Medical Necessity
- Aptiom tablet
- Brilinta tablet
- Entresto tablet
- Nityr tablet
- Orfadin capsule and suspension
- Remove Medical Necessity
- Wyost injection
- Jubbonti injection
Removed from Formulary
- Acetasol HC solution 2-1%
- Actigall capsule 300 mg
- AK-Poly-Bac ointment 500-10000 unit/gm
- Albuminar-25 Solution 25%
- Aldactazide Tablet 25-25 mg
- Alfenta injection 500 mg/mL
- Amicar syrup 25%
- Aminoacetic acid solution 1.5%
- Aminoacetic Acid solution 1.5%
- Aminosyn II solution 7%
- Aminosyn II solution 8.5%
- Aminosyn II/Electrolytes solution 8.5%
- Aminosyn solution 10%
- Aminosyn solution 7%
- Aminosyn solution 8.5%
- Aminosyn/Electrolytes solution 7%
- Aminosyn-HBC solution 7%
- Aminosyn-PF solution 7%
- Aminosyn-RF solution 5.2%
- AVC Vaginal cream 15% Vaginal
- Emend capsule 125 mg; 40 mg; 80 and 125 mg; 80 mg
- Nicotrol inhalation
Quantity Limit
- Update
- Aptiom tablet
- Sancuso patch
Tier placement
- Update
- Fingolimod capsule
Add to Specialty Pharmacy
- Tyvaso inhalation
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2025. The following changes to the drug list are effective October 22, 2025:
Formulary Additions
- Andembry injection add tier 4 with SP, quantity limit, and prior authorization
- Averi topical kit add tier 0
- Bomyntra injection add tier 4 with SP and prior authorization
- Conexxence injection add tier 4 with SP and prior authorization
- Ekterly tablet add tier 4 with SP, limited access, quantity versus time limit, and prior authorization
- Ibtrozi capsule add tier 4 with SP, limited access, quantity limit, and prior authorization
- Jubbonti injection add tier 4 with SP and prior authorization
- Osenvelt injection add tier 4 with SP and prior authorization
- Rivaroxaban tablet and suspension add tier 1 with quantity limit
- Ryzneuta injection add tier 4 with SP and prior authorization
- Sacubitril/valsartan tablet add tier 1 with quantity limit
- Stoboclo injection add tier 4 with SP and prior authorization
- Tybost add tier 2 with quantity limit
- Tybost tablet add tier 2
- Wyost injection add tier 4 with SP and prior authorization
- Yeztugo tablet and injection add to tier 0
- Zelsuvmi gel add tier 3 with quantity limit and prior authorization
- Zevaskyn gene therapy add tier 4 with SP and prior authorization
Removed from Formulary
- Brilinta tablet, consider ticagrelor tablet
- Entresto tablet, consider sacubitril/valsartan tablet
- Nicotrol inhalation
- Nityr tablet, consider nitisinone tablet
- Orfadin capsule and suspension, consider nitisinone tablet
Quantity Limit
- Update
- Nubeqa tablet
- Sancuso patch
- Testosterone gel 20.25 mg/1.25 (1.62%) gm transdermal
See the PacificSource Drug Lists page for the current drug list.