Provider Notices

Coverage Updates Effective 12/1/14 (Now Changed to Effective 2/1/15)

12/12/2014 2:08:08 PM

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. These changes are effective for dates of service on or after February 1, 2015.

Please review the summary of these changes below:

Drug Name Change Effective Date
Amlodipine/Valsartan/Hydrochlorothiazide Exforge-hctz Remove 2/1/2015
Ciclopirox lotion, cream, gel, shampoo Remove 2/1/2015
Cyclosporine Gengraf capsules, solution, modified Remove 2/1/2015
Cyclosporine Neoral Remove 2/1/2015
Cyclosporine Sandimmune capsules, solutions, injection Remove 2/1/2015
Ecallantide Kalbitor Pre-Approval Policy Change 2/1/2015
Econazole Nitrate topical cream Remove 2/1/2015
Famotidine oral suspension Remove 2/1/2015
Hyaluronic Acid derivatives Remove/Pre-Approval Policy Change 2/1/2015
Hydrocortisone/Pramoxine PramCort cream Remove 2/1/2015
Icatibant Firazyr Pre-Approval Policy Change 2/1/2015
Lamivudine Epirivir solution Remove 2/1/2015
Lansoprazole/Amoxicillin/Clarithromycin combination product Remove 2/1/2015
Mesna Mesnex Remove 2/1/2015
Metaxalone Remove 2/1/2015
Naftin gel Remove 2/1/2015
Prednisolone Acetate Blephamide Remove 2/1/2015
Tizanidine capsule Remove 2/1/2015

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

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.