CommercialPrior AuthHigh impact
May 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·OR, ID, MT, WA · Internal Medicine, Endocrinology, Neurology +4 more·Prior Authorization
Effective date
May 22, 2026
We identified it
Mar 18, 2026
Summary
PacificSource updated its commercial drug formulary effective May 22, 2026, adding 10 new medications with tier 3 (or tier 4 in OR/ID/MT/WA) designations and various restrictions including prior authorization, quantity limits, and step therapy requirements. The update also retired the Fibrates policy due to drug discontinuation, modified prior authorization criteria for 13 drug classes, and removed 4 drugs from the formulary (Acyclovir solution, Megace ES suspension, Sitavig tablet, Triglide tablet).
Action Required
By May 22, 2026: (1) Billing team must update billing software to reflect all formulary additions and deletions listed in this policy. (2) Configure the system to automatically trigger prior authorization requests for all newly added drugs (Aqvesme, Cardamyst, Cladribine, Exdensur, Furoscix, Hyrnuo, Lasix ONYU, Omlonti, Pivya, Voyxact, Vraylar) before claim submission. (3) Remove billing codes for discontinued drugs (Acyclovir solution 500mg, Megace ES suspension, Sitavig tablet, Triglide tablet) from encounter forms and billing templates to prevent submission errors. (4) Update quantity limit enforcement rules in the pharmacy billing system for all affected medications. (5) Clinical staff must review updated prior authorization criteria for the 13 modified drug classes (Addyi, Anti-Herpetic Agents, Cablivi, CGRP Inhibitors, Continuous Glucose Monitors, ETA Receptor Antagonists, Megestrol, Mitapivat, Nusinersen, Omidubicel, Oncology Agents, Proximal Complement Inhibitor, Risdiplam, Targeted Immune Modulators) and implement new medical necessity requirements. (6) Front desk staff must update patient copay/cost-sharing information for tier 3/tier 4 drugs. Failure to implement these changes will result in claim denials for newly formulary drugs without proper prior auth authorization and billing rejections for removed drugs.