CommercialCoverageHigh impact
October 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·OR, ID, MT, WA · Cardiology, Endocrinology, Gastroenterology +9 more·Prior Authorization
Effective date
Oct 22, 2026
We identified it
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.
Action Required
By October 22, 2026: (1) Billing 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. (2) Update prior authorization workflow for all new drugs requiring PA, including medical necessity determinations for medications like Atuncy, Awiqli, Bysanti, Quiofic, and Ryaltris. (3) Implement quantity limit enforcement in billing system for affected drugs (Tremfya, Uptravi, and all tier 3+ additions). (4) For state-based plans (OR, ID, MT, WA), apply different tier levels (tier 4 vs tier 3 for most drugs). (5) Remove 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). (6) Update encounter forms and prior auth templates to capture medical necessity documentation for applicable medications. (7) Coordinate with providers to communicate tier changes and generic substitutions. Failure to implement changes will result in claim denials and patient out-of-pocket cost disputes.