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October 2026 Drug List Change Notification (Commercial)
Act
by Oct 22, 2026
Effective date
Oct 22, 2026
Identified
Aug 21, 2026
Summary
Effective October 22, 2026, PacificSource is implementing major formulary changes affecting 40+ medications across commercial and state-based plans (OR, ID, MT, WA). Changes include new drug additions at various tiers with prior authorization and quantity limits, removal of brand-name drugs with generic alternatives, and updates to prior authorization criteria for multiple drug classes. Billing teams must update systems to reflect new tier placements, prior authorization requirements, and quantity limit enforcement.
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What to do
by Oct 22, 2026 · 7 steps
01Billing team must update pharmacy benefit system to reflect 40+ new formulary additions with correct tier levels, prior authorization flags, quantity limits, and specialty pharmacy (SP) designations.
02Update prior authorization workflow for all new drugs requiring PA, including medical necessity determinations for medications like Atuncy, Awiqli, Bysanti, Quiofic, and Ryaltris.
03Implement quantity limit enforcement in billing system for affected drugs (Tremfya, Uptravi, and all tier 3+ additions).
04For state-based plans (OR, ID, MT, WA), apply different tier levels (tier 4 vs tier 3 for most drugs).
05Remove from formulary and direct patients to generic alternatives: Bosulif, Gamastan, Janumet, Janumet XR, Januvia, Jynarque, Nucynta, Nuedexta, Opsumit, Pomalyst, Sandostatin, Tasigna, Torisel, Xeljanz (all forms).
06Update encounter forms and prior auth templates to capture medical necessity documentation for applicable medications.
07Coordinate with providers to communicate tier changes and generic substitutions.
If missed: Failure to implement changes will result in claim denials and patient out-of-pocket cost disputes.
Original notice
October 2026 Drug List Change Notification (Commercial)
pacificsource.com · Always check the source before changing claims.
Related changes
See all PacificSource Health Plans changes →August 2026 Drug List Change Notification (Commercial)HighEffective Aug 22, 2026 · Prior AuthorizationJune 2026 Drug List Change Notification (Commercial)HighEffective Jun 22, 2026 · Prior AuthorizationMay 2026 Drug List Change Notification (Commercial)HighEffective May 22, 2026 · Prior AuthorizationOctober 2025 Drug List Change Notification (Commercial)HighEffective Oct 22, 2025 · Prior AuthorizationBrowse every PacificSource Health Plans change in the policy list