Coverage Updates Effective April 15, 2016 – Medicaid Formulary

2/23/2016 8:22:33 AM

Network Providers
PacificSource Community Solutions, Inc.

Coverage Updates Effective April 15, 2016

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 15, 2016.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

Astagraf XL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG ORAL

remove

04/15/2016

 

Astagraf XL CAPSULE EXTENDED RELEASE 24 HOUR 1 MG ORAL

remove

04/15/2016

Astagraf XL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG ORAL

remove

04/15/2016

Relenza Diskhaler AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER INHALATION

Quantity Limit #20/60 days

04/15/2016

Tamiflu CAPSULE 30 MG ORAL

Quantity Limit #20/60 days

04/15/2016

Tamiflu CAPSULE 45 MG ORAL

Quantity Limit #10/60 days

04/15/2016

Tamiflu CAPSULE 75 MG ORAL

Quantity Limit #10/60 days

04/15/2016

Tamiflu SUSPENSION RECONSTITUTED 6 MG/ML ORAL

Quantity Limit #180/60 days

04/15/2016

Carisoprodol TABLET 350 MG ORAL

remove

04/15/2016

Carisoprodol-Aspirin TABLET 200-325 MG ORAL

remove

04/15/2016

Carisoprodol-Aspirin-Codeine TABLET 200-325-16 MG ORAL

remove

04/15/2016

EpiPen Jr 2-Pak 0.15 MG/0.3ML INJECTION

remove

04/15/2016

Budesonide SUSPENSION 0.5 MG/2ML INHALATION

Quantity Limit #120/30 days

04/15/2016

Tyzeka TABLET 600 MG ORAL

remove

04/15/2016

Sivextro SOLUTION RECONSTITUTED 200 MG INTRAVENOUS

Quantity Limit #6/30 days

04/15/2016

Zolinza CAPSULE 100 MG ORAL

pre-approval policy change

04/15/2016

Xarelto TABLET 10 MG ORAL

Quantity Limit #30/30 days

04/15/2016

Eliquis TABLET 2.5 MG ORAL

Quantity Limit #60/30 days

04/15/2016

ValGANciclovir HCl TABLET 450 MG ORAL

Quantity Limit #400/365 days

04/15/2016

Diazepam Rectal Gel Delivery System 10 MG

Quantity Limit #5/30 days

04/15/2016

Diazepam Rectal Gel Delivery System 2.5 MG

Quantity Limit #5/30 days

04/15/2016

Diazepam Rectal Gel Delivery System 20 MG

Quantity Limit #5/30 days

04/15/2016

Zostavax SOLUTION RECONSTITUTED 19400 UNT/0.65ML SUBCUTANEOUS*

Age restriction change - Minimum age: 60 years

04/15/2016

Tramadol-Acetaminophen TABLET 37.5-325 MG ORAL

Quantity Limit #240/30 days

04/15/2016

Doxazosin Mesylate TABLET 1 MG ORAL

Quantity Limit #60/30 days

04/15/2016

Doxazosin Mesylate TABLET 2 MG ORAL

Quantity Limit #60/30 days

04/15/2016

Doxazosin Mesylate TABLET 4 MG ORAL

Quantity Limit #30/30 days

04/15/2016

Doxazosin Mesylate TABLET 8 MG ORAL

Quantity Limit #30/30 days

04/15/2016

Paromomycin Sulfate CAPSULE 250 MG ORAL

Quantity Limit #168/21 days

04/15/2016

Tretinoin CAPSULE 10 MG ORAL

Quantity Limit #810/365 days

04/15/2016

Cyclobenzaprine HCl TABLET 7.5 MG ORAL

remove

04/15/2016

Nicotrol NS SOLUTION 10 MG/ML NASAL

Quantity Limit #720/365 days

04/15/2016

Prevacid 24HR CAPSULE DELAYED RELEASE 15 MG ORAL

remove

04/15/2016

Prevacid CAPSULE DELAYED RELEASE 15 MG ORAL

remove

04/15/2016

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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