December 2026 Drug List Change Notification (Commercial)

By December 22, 2026: Billing team must implement the following changes in the billing system and prior authorization workflows: (1) Add 24 new medications to the formulary with their assigned tiers (tier 0–4), quantity limits, medical necessity requirements, and prior authorization triggers as specified for both commercial and state-based plans; (2) Update prior authorization criteria for BCR-ABL Tyrosine Kinase Inhibitors, Zepbound, GLP-1 Receptor Agonists, Intravitreal Anti-VEGF Therapy, Neonatal FC Receptor Antagonists, Oncology Agents, Proximal Complement Inhibitors, Pulmonary Hypertension Agents, and Targeted Immune Modulators; (3) Remove prior authorization requirement for Breztri aerosol and update its tier status; (4) Apply medical necessity prior authorization to Corlanor (tablet and solution) and Revlimid capsule; (5) Remove medical necessity requirement from Yutrepia powder; (6) For state-based plans (OR, ID, MT, WA), remove Corlanor and Revlimid from formulary and offer generic alternatives (ivabradine and lenalidomide respectively); (7) For Savella tablet on state-based plans, recommend generic milnacipran tablet. Reference the current PacificSource Drug Lists page to verify all tier placements, specialty pharmacy (SP) designations, limited access restrictions, and quantity limit specifications. Coordinate with prior authorization staff and claims processors to ensure denials do not occur due to missing updated criteria.