Updates on Existing Criteria
October 2026. The following changes to criteria are effective by October 22, 2026:
Prior Authorization Criteria – Clinical Updates
- Apoc-III Targeted Agents – update initial authorization criteria
- Aprocitentan – replace with policy named Adjunctive Antihypertensive Drugs and update affected medications
- Denosumab – update affected medications
- Endothelin Receptor Antagonists – Update affected medications and appropriate treatment
- Ergot Alkaloids – remove policy
- Exagamglogene Autotemcel – update covered uses and age restriction
- Immune Globulin – update affected medications
- Intravitreal Anti-VEGF therapy – update covered uses and appropriate treatment
- Marstacimab – update age restriction
- Medical Necessity – update affected medications
- Myeloid Growth Factors – update affected medications, covered uses, and appropriate treatment
- Neonatal FC Receptor Antagonists – update covered uses
- Oncology Agents – update affected medications
- Opioids (long-acting) – update step therapy drugs
- Opioids-Nucynta – update step therapy drugs
- Tepezza – replace with policy named Thyroid Eye Disease (TED) Agents and update affected medications, appropriate treatment, and coverage duration
- Tzield – update covered uses, required medical information, appropriate treatment, age-restriction, and coverage duration
- Xgeva – update affected medications
Preferred Drug List (PDL) Changes
October 2026. The following changes to the drug list are effective October 22, 2026:
Formulary Additions
- Atoncy solution add tier 3 with medical necessity prior authorization
- Awiqli injection add tier 2 with medical necessity prior authorization
- Baxfendy tablet add tier 3 with quantity limit and prior authorization
- Bosutinib tablet add tier 3 with SP, quantity limit, and prior authorization
- Bysanti tablet add tier 3 with quantity limit and medical necessity prior authorization
- Capvaxive injection add tier 0
- Dextromethorphan/quinidine capsule add tier 3 with SP, quantity limit, and prior authorization
- Doxycycline hyclate 75 mg capsule add tier 1 with medical necessity prior authorization
- Duloxetine authorized generic add Tier 1 and medical necessity prior authorization
- Fesilty kit add tier 3 with quantity limit and medical necessity prior authorization
- Gammagard ERC liquid add tier 3 with SP and prior authorization
- Hepcludex injection add tier 3 with SP, limited access, quantity limit, and prior authorization
- Jubereq injection add tier 3 with SP and medical necessity prior authorization
- Lynavoy tablet add tier 3 with SP, limited access, quantity limit, and medical necessity prior authorization
- Macitentan tablet add tier 3 with SP, quantity limit, and prior authorization
- Nilotinib capsule add tier 3 with SP, quantity limit, and prior authorization
- Octreotide acetate injection add tier 3 with SP, and prior authorization
- Osvyrti injection add tier 3 with SP and medical necessity prior authorization
- Ozempic tablet add tier 2 with quantity limit and prior authorization
- Pomalidomide capsule add tier 3 with SP, quantity limit, and prior authorization
- Quiofic solution add tier 3 with medical necessity prior authorization
- Ryaltris nasal spray add tier 3 with quantity limit and medical necessity prior authorization
- Sitagliptin tablet add tier 2 with quantity limit
- Sitagliptin-metformin extended-release tablet add tier 2 with quantity limit
- Sitagliptin-metformin tablet add tier 2 with quantity limit
- Skyrizi 55 mg/0.37 mL injection add tier 3 with SP, quantity liit, and prior authorization
- Tapentadol ER tablet add Tier 3 with step therapy and MME prior authorization
- Tapentadol tablet add Tier 3 with step therapy and morphine milligram equivalents (MME) prior authorization
- Tofacitinib ER tablet add tier 3 with SP, quantity limit, and prior authorization
- Tofacitinib solution add tier 3 with SP, quantity limit, and prior authorization
- Tofacitinib tablet add tier 3 with SP, quantity limit, and prior authorization
- Tolvaptan kit add tier 3 with SP, limited access, quantity limit, and prior authorization
- Trutakna injection add tier 3 with SP, quantity limit, and medical necessity prior authorization
- Veppanu tablet add tier 3 with SP, quantity limit, and medical necessity prior authorization
- Wilate solution add tier 3 with SP and prior authorization
- Xocova tablet add tier 3 with quantity versus time limit
Add Quantity Limit
- Tremfya injection
- Uptravi tablet
Medical Necessity
- Add Medical Necessity
- Bosulif tablet
- Gamastan injection
- Janumet tablet
- Janumet XR tablet
- Januvia tablet
- Jynarque kit
- Nucynta tablet
- Nuedexta capsule
- Opsumit tablet
- Pomalyst capsule
- Sandostatin injection
- Tasigna capsule
- Torisel solution
- Xeljanz ER tablet
- Xeljanz solution
- Xeljanz tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
October 2026. The following changes to the drug list are effective October 22, 2026:
Formulary Additions
- Awiqli injection add tier 2 with medical necessity prior authorization
- Bosutinib tablet add tier 4 with SP, quantity limit, and prior authorization
- Capvaxive injection add tier 0
- Dextromethorphan/quinidine capsule add tier 4 with SP, quantity limit, and prior authorization
- Gammagard ERC liquid add tier 3 with SP and prior authorization
- Hepcludex injection add tier 4 with SP, limited access, quantity limit, and prior authorization
- Macitentan tablet add tier 4 with SP, quantity limit, and prior authorization
- Nilotinib capsule add tier 4 with SP, quantity limit, and prior authorization
- Octreotide acetate injection add tier 4 with SP, and prior authorization
- Ozempic tablet add tier 2 with quantity limit and prior authorization
- Pomalidomide capsule add tier 4 with SP, quantity limit, and prior authorization
- Sitagliptin tablet add tier 2 with quantity limit
- Sitagliptin-metformin extended-release tablet add tier 2 with quantity limit
- Sitagliptin-metformin tablet add tier 2 with quantity limit
- Skyrizi 55 mg/0.37 mL injection add tier 4 with SP, quantity limit, and prior authorization
- Tapentadol ER tablet add Tier 3 with step therapy and MME prior authorization
- Tapentadol tablet add Tier 3 with step therapy and morphine milligram equivalents (MME) prior authorization
- Tofacitinib ER tablet add tier 4 with SP, quantity limit, and prior authorization
- Tofacitinib solution add tier 4 with SP, quantity limit, and prior authorization
- Tofacitinib tablet add tier 4 with SP, quantity limit, and prior authorization
- Tolvaptan kit add tier 4 with SP, limited access, quantity limit, and prior authorization
- Wilate solution add tier 4 with SP and prior authorization
- Xocova tablet add tier 3 with quantity versus time limit
Add Quantity Limit
- Tremfya injection
Remove from Formulary
- Bosulif tablet; consider generic bosutinib tablet
- Gamastan injection; consider generic human immune globulin
- Janumet tablet; consider generic sitagliptin-metformin tablet
- Janumet XR tablet; consider generic sitagliptin-metformin extended-release tablet
- Januvia tablet; consider generic sitagliptin tablet
- Jynarque kit; consider generic tolvaptan kit
- Nucynta tablet; consider generic tapentadol, hydromorphone, methadone, morphine, oxycodone, oxymorphone, tramadol
- Nuedexta capsule; consider generic dextromethorphan/quinidine capsule
- Opsumit tablet; consider generic macitentan tablet
- Pomalyst capsule; consider generic pomalidomide capsule
- Sandostatin injection; consider generic octreotide acetate injection
- Tasigna capsule; consider generic nilotinib capsule
- Torisel solution; consider generic temsirolimus solution (medical benefit only)
- Xeljanz ER tablet; consider generic tofacitinib ER tablet
- Xeljanz solution; consider generic tofacitinib solution
- Xeljanz tablet; consider generic tofacitinib tablet
See the PacificSource Drug Lists page for the current drug list.