Coverage Updates Effective September 1, 2014 - Medicaid Formulary

8/6/2014 11:25:50 AM

We would like to inform you of changes to our PacificSource Community Solutions’ formulary and coverage policies.

We have recently updated our prior authorization list and coverage policies for our 2014 Medicaid plans. These changes are effective for dates of service on or after September 1, 2014.

Please review the summary of these changes below:

Drug Name Change Effective Date
Clonidine Pre-Approval Policy Change 09/01/2014
Cyproheptadine Remove 09/01/2014
Dabrafenib [Tafinlar] Pre-Approval Policy Change 09/01/2014
Denosumab [Xgeva] Pre-Approval Policy Change 09/01/2014
Dofetilide capsule [Tikosyn] Remove 09/01/2014
Enteral Nutrition Pre-Approval Policy Change 09/01/2014
Guanfacine Pre-Approval Policy Change 09/01/2014
Ibrutinib [Imbruvica] Pre-Approval Policy Change 09/01/2014
Ipilimumab [Yeryov] Pre-Approval Policy Change 09/01/2014
Meclofenamate Sodium Remove 09/01/2014
Mefenamic Step Therapy Policy Change 09/01/2014
Methazolamide Remove 09/01/2014
Nisolodipine Remove 09/01/2014
Ofatumumab [Arzerra] Pre-Approval Policy Change 09/01/2014
Omalizumab [Xolair] Pre-Approval Policy Change 09/01/2014
OnabotulinumtoxinA [Botox] Pre-Approval Policy Change 09/01/2014
Opioids Quantity Limit Change:
  • Most restrictive policy applies out of the following:
  • Max of 120 mg Morphine equivalent per day
  • Max of 12 tablets per day for immediate release
  • Max of 4 tablets per day of extended release
  • Max of 4,000 mg of Acetaminophen per day
09/01/2014
Quinidine Gluconate ER Remove 09/01/2014
Trametinib [Mekinist] Pre-Approval Policy Change 09/01/2014
Fluticasone Propionate/Salmeterol [Advair] Remove 09/01/2014
Enzyme Replacement Therapies Pre-Approval Policy Change 09/01/2014
Compounded Drugs Pre-Approval Policy Change 09/01/2014
Anti-Fungals Step Therapy Policy Change 09/01/2014
Terbinafine Remove 09/01/2014
Rituximab [Rituxan] Pre-Approval Policy Change 09/01/2014
Vismodegib [Erivedge] Pre-Approval Policy Change 09/01/2014
Clobetasol shampoo, cream, foam & lotion Remove 09/01/2014
Desonide cream & ointment Remove 09/01/2014
Amcinoninde Remove 09/01/2014
Prednicarbate Remove 09/01/2014

In addition to the above changes, we have updated the formulary to include a number of new medications that have been released in the last year. For a complete formulary listing, please visit our website at www.CommunitySolutions.PacificSource.com

If you have questions regarding these changes, please contact your PacificSource Provider Service Representative or the PacificSource Pharmacy Services Department at (888) 437-7728 or (541) 330-4999.


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