June 2025 Drug List Change Notification (Commercial)

April 18, 2025

Updates on Existing Criteria

June 2025. The following changes to criteria are effective June 22, 2025:

Prior Authorization Criteria – Clinical Updates

Alemtuzumab – update appropriate treatment
Apomorphine – remove Kynmobi from affected medications, updates required medical information, and appropriate treatment regimen
Avonex, Betaseron, Plegridy, and Rebif – combine policies to “Interferons for Multiple Sclerosis”
Benralizumab – update required medical information and prescriber restriction
Cannabidiol – update required medical information and appropriate treatment regimen
Cladribine – update exclusion criteria
Diroximel Fumarate and Monomethyl Fumarate – combine policies to “Fumarates for Multiple Sclerosis”
Dupilumab – update required medical information and appropriate treatment regimen
Eculizumab – add Epysqli and Bkemv to affected medications, update covered uses, and age restriction
Enfuvirtide – remove policy
Fidanacogene – remove policy
Flucytosine – update covered uses, required medical information, appropriate treatment regimen, and coverage duration
Glucagon-like Peptide (GLP-1) Receptor Agonist – update covered uses, required medical information, appropriate treatment regimen, and exclusion criteria
Intravitreal Anti-VEGF Therapy – remove Vabysmo and add Susvimo to affected medications, update covered uses, required medical information, and appropriate treatment regimen
Lemtrada – update appropriate treatment regimen
Maribavir - update covered uses, required medical information, appropriate treatment regimen, exclusion criteria, and coverage duration
Mepolizumab – update required medical information, appropriate treatment regimen, and prescriber restriction
Migraine Agents- remove Axert from affected drugs
Mometasone Sinus Implant – update required medical information, appropriate treatment regimen, exclusion criteria, and coverage duration
Omalizumab – update required medical information and appropriate treatment regimen
Oncology Agents – remove Kisqali and Kisqali Femara from and place under new policy “Ribociclib”
Opioids (Long-Acting) – remove Exalgo from affected drugs
Overactive Bladder – remove Enablex from affected drugs
Ozanimod, Siponimod, and Ponvory – combine policies to “Sphingosine 1-Phosphate (S1P) Receptor Modulators”
Palivizumab – update required medical information, appropriate treatment regimen, exclusion criteria, age restriction, prescriber restriction, and coverage duration
Parathyroid Hormone Analogs – update appropriate treatment regimen
Pramlintide – remove policy
Rituximab – update required medical information, appropriate treatment regimen, and prescriber
Rosacea Topical – remove Soolantra from affected drugs
Selumetinib –replace with new “MEK Inhibitors for Neurofibromatosis Type 1 (NF1)”
Sparsentan – update covered uses, appropriate treatment regimen, exclusion criteria, and prescriber restriction,
Spravato – update covered uses and appropriate treatment regimen
Targeted Immune Modulators – update non-preferred medical drugs
Tarpeyo – update required medical information, appropriate treatment regimen, and exclusion criteria
Vyalev - update policy name to “Infusions for Advanced Parkinson’s Disease,” add Onapgo to affected medications, update required medical information, appropriate treatment, exclusion criteria, and age restriction

Preferred Drug List (PDL) Changes

June 2025. The following changes to the drug list are effective June 22, 2025:

Formulary Additions

Adalimumab-adaz injection 80 mg/0.8 mL, 20 mg/0.2 mL, and 10 mg/0.1 mL add tier 3 with SP, quantity limit, and prior authorization
Alhemo injection add tier 3 with SP and prior authorization
Caya diaphragm add tier 0 with quantity limit
Evrysdi add tier 3 with SP, limited access, quantity limit, and prior authorization
Gomekli capsule and tablet add tier 3 with SP, limited access, quantity limit, and prior authorization
Inzirqo suspension add tier 3 with quantity limit and medical necessity prior authorization
Jivi injection add tier 3 with SP and prior authorization
Journavx tablet add tier 3 with quantity limit and prior authorization
Mesna tablet add tier 1
Minzoya tablet add tier 0
Omnipod 5 Libre 2 Plus G6 Kit and Pods add Tier 2 with quantity limit
Omvoh 300 mg dose injection add tier 3 with SP, quantity limit, and medical necessity prior authorization
Onapgo solution add tier 3 with SP, quantity limit, and prior authorization
Otulfi injection add tier 3 with SP, limited access, and medical necessity prior authorization
Prevymis packet add tier 3 with quantity limit and prior authorization
Pyzchiva injection add tier 3 with SP, limited access, and medical necessity prior authorization
Raldesy solution add tier 3 with quantity limit and medical necessity prior authorization
Romvimza capsule add tier 3 with SP, limited access, quantity limit, and prior authorization
Rybelsus tablet 1.5 mg, 4 mg, and 9 mg add tier 2, with quantity limit and prior authorization
Selarsdi injection add tier 3 with SP, limited access, and medical necessity prior authorization
Simlandi injection add tier 3 with SP, quantity limit, and medical necessity prior authorization
Valtya 1/50 tablet add tier 0
Xarah Fe tablet add tier 0
Xromi solution add tier 3 with medical necessity prior authorization
Yesintek injection add tier 3 with SP, limited access, and medical necessity prior authorization
Zunveyl tablet add tier 3 with quantity limit and medical necessity prior authorization

Prior Authorization

Remove Prior Authorization
- SymlinPen injection

Add Medical Necessity
- Inzirqo suspension
- Mesnex tablet
- Omvoh 300 mg dose injection
- Otulfi injection
- Pyzchiva injection
- Raldesy solution
- Simlandi injection
- Vuity solution
- Xromi solution
- Yesintek injection
- Zunveyl tablet

Remove Medical Necessity
- Ibrance tablet and capsule

Removed from Formulary

Avelox tablet
Bio-statin capsule
Calquence capsule
Extavia solution
Fuzeon injection
Gris-PEG tablet
Kynmobi sublingual film
Lamisil tablet
Moxatag tablet
Myambutol tablet
OmniPod 10 Pack
Omnipod Classic Pods and kit
Onmel tablet
Paser packet
Rifadin capsule
Rifamate capsule
Rifater tablet
Seromycin capsule
Tydemy tablet

Quantity Limit

Update
- Lumakras tablet
- Prevymis tablet
- SymlinPen injection

Add to Specialty Pharmacy

Odefsey tablet

See the PacificSource Drug Lists page for the current drug list.

State Based Drug List (OR, ID, MT, WA) Changes