CommercialPrior AuthHigh impact
April 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·OR, ID, MT, WA · Endocrinology, Internal Medicine, Family Medicine·Prior Authorization
Effective date
Apr 9, 2026
We identified it
Feb 9, 2026
Summary
PacificSource is implementing significant changes to GLP-1 receptor agonist prior authorization criteria, adding Tofidence as a tier 3 formulary drug with medical necessity requirements, updating quantity limits for Journavx Nurtec, and adding formulary exception criteria for Nurtec tablet across commercial plans and state-based drug lists (OR, ID, MT, WA). All changes are effective April 9, 2026.
Action Required
By April 9, 2026: (1) Billing team must update billing system to require prior authorization for all GLP-1 receptor agonist prescriptions with updated clinical criteria, required medical information, and exclusion criteria. (2) Coding/billing staff must implement new tier 3 status for Tofidence subcutaneous solution with quantity limits and medical necessity prior auth requirements. (3) Update Journavx Nurtec quantity limits in formulary database per PacificSource Drug Lists page. (4) For state-based plans (OR, ID, MT, WA): Apply updated quantity limits for Journavx and add new formulary exception criteria policy for Nurtec tablet. (5) Verify provider documentation includes required medical information for GLP-1 authorizations to avoid claim denials. (6) Consult PacificSource Drug Lists page immediately for exact quantity limits and tier details. (7) Train billing and prior auth staff on updated exclusion criteria to prevent inappropriate authorizations.