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Prescription drug lists and criteria

Prescription drug lists and criteria
Zero dollar prescription

Affordable Care Act Standard Preventive No-cost Drug List (CVS Caremark)

The ACA Standard Preventive No-cost Drug List contains medications required by the government to be available at no cost to members of a health insurance plan. The list is maintained by CVS Caremark.  

PacificSource Expanded Preventive No-cost Drug List

The Expanded No-Cost Drug List is included in our individual and small-group plans, and is an optional benefit for large groups. With this benefit, the drugs listed below are paid at 100 percent. This list is a separate benefit from preventive service drugs covered under the Affordable Care Act.

Value Based
Preventive No-cost
Drug List


The Value Based Preventive No-cost Drug List is offered to select self-funded groups. With this benefit, the drugs listed are paid at 100 percent. This list is a separate benefit from the one that covers preventive service drugs under the Affordable Care Act.

Incentive Drug List

The Incentive Drug List is offered to select large employer groups. For copays, see your summary of benefits.

Utilization Management

For certain prescription drugs, we have additional coverage requirements or limits. Learn more about utilization management, including prior authorization, quantity limits, and step therapy.

Opioid FAQ for commercial providers

To aid in fighting the opioid epidemic, and thus reduce health risks in our community, we are working toward lowering the total dose of opioids that a member can receive per day. This measurement is called MME (Morphine Milligram Equivalent). We are gradually lowering the MME threshold through May 22, 2022.

For more information, please download the opioid FAQ.

Sharing updates with you is important to us

PacificSource Drug Lists are updated monthly, and we do our best to notify members of changes 30 days in advance. Our team of physicians and pharmacists meets regularly to recommend changes to our drug lists based on the latest medical studies and current clinical Food and Drug Administration guidelines.

Drug List Changes

The following notifications include updates to the PacificSource Preferred Drug List (PDL) and the state-based (ID, MT, OR, WA) drug lists.

Emergency fills for Washington members

For urgently needed medications during our non-business hours.

Washington emergency fill procedures