Coverage Updates Effective December 15, 2015 – Medicaid Formulary

11/4/2015 9:32:08 AM

Network Providers
PacificSource Community Solutions, Inc.

Coverage Updates Effective December 15, 2015

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 December 15, 2015.

Please review the summary of these changes below:

Drug Name Change Effective Date
BCG Vaccine INJECTABLE Remove 12/15/2015
Imovax Rabies INJECTABLE Remove 12/15/2015
ProAir RespiClick AEROSOL POWDER Remove 12/15/2015
RabAvert SUSPENSION Remove 12/15/2015
Typhim VI SOLUTION Remove 12/15/2015
Vivotif Berna Vaccine CAPSULE Remove 12/15/2015

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 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.

Sincerely,
Provider Network
PacificSource Community Solutions, Inc.


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