Coverage Updates Effective April 8, 2015

3/5/2015 2:24:21 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 April 8, 2015.

Please review the summary of these changes below:

Drug Name Change Effective Date
Relistor (methylnaltrexone) Pre-approval policy change 4/8/2015
Prenatal vitamins Age restriction change (only covered for women 45 years and younger) 4/8/2015
Multivitamins with or without fluoride Age restriction change (only covered for members 10 years and younger) 4/8/2015
Rituxan (rituximab) Pre-approval policy change 4/8/2015
Humira (adalimumab) Pre-approval policy and quantity limit change 4/8/2015
Enbrel (etanercept) Pre-approval policy and quantity limit change 4/8/2015
Orencia (abatacept) Pre-approval policy and quantity limit change 4/8/2015
Simponi (golimumab) Pre-approval policy and quantity limit change 4/8/2015
Actemra (tocilizumab) Pre-approval policy and quantity limit change 4/8/2015
Kineret (anakinra) Pre-approval policy and quantity limit change 4/8/2015
Remicade (infliximab) Pre-approval policy change 4/8/2015
Xeljanz (tofacitinib) Pre-approval policy and quantity limit change 4/8/2015
Cimzia (certolizumab pegol) Pre-approval policy and quantity limit change 4/8/2015
Chlorthalidone 100 mg Remove 4/8/2015
Nitrocglycerin ER capsules Remove 4/8/2015
buprenorphine injection Remove 4/8/2015
Victrelis (boceprevir) Remove 4/8/2015
Xifaxan (rifaximin) Pre-approval policy change 4/8/2015
Banzel (rufinamide) Pre-approval policy change 4/8/2015
Olysio (simeprevir) Remove 4/8/2015

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 www.communitysolutions.pacificsource.com/Tools/DrugSearch.

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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