Provider Notices


Pharmacy Coverage Updates Effective March 15, 2018

1/25/2018 11:47:38 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. These changes are effective for dates of service on or after March 15, 2018.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

Meperidine HCL injection 50 MG/ML

Medical Benefit Only

  3/15/2018

Morphine Sulfate (PF) SOLUTION 10 MG/ML INTRAVENOUS

Medical Benefit Only

  3/15/2018

Morphine Sulfate Injection 10 MG/ML

Medical Benefit Only

  3/15/2018

Gentamicin Sulfate Injection 10 MG/ML

Medical Benefit Only

  3/15/2018

Zurampic TABLET 200 MG Oral

Remove, use Allopurinol, Probenecid

  3/15/2018

Pradaxa CAPSULE 150 MG ORAL

Remove, use Eliquis, Xarelto

  3/15/2018

Pradaxa CAPSULE 75 MG ORAL

Remove, use Eliquis, Xarelto

  3/15/2018

Methadone HCl TABLET SOLUBLE 40 MG ORAL

Remove, use Methadone 10mg tablet

  3/15/2018

First-Omeprazole SUSPENSION

Remove, use Omeprazole CAPSULE DELAYED RELEASE, Lansoprazole CAPSULE DELAYED RELEASE, Cimetidine HCl SOLUTION ORAL, Ranitidine HCl SYRUP ORAL

  3/15/2018

First-Lansoprazole SUSPENSION

Remove, use Omeprazole CAPSULE DELAYED RELEASE, Lansoprazole CAPSULE DELAYED RELEASE, Cimetidine HCl SOLUTION ORAL, Ranitidine HCl SYRUP ORAL

  3/15/2018

Kalydeco PACKET 50 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Kalydeco PACKET 75 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Simponi 100 MG/ML SUBCUTANEOUS*

Add Quantity Limit #1/28 days

  3/15/2018

Simponi 50 MG/0.5ML SUBCUTANEOUS*

Add Quantity Limit #0.5/28 days

  3/15/2018

Simponi Solution Auto-injector 50 MG/0.5ML Subcutaneous

Add Quantity Limit #0.5/28 days

  3/15/2018

Entresto TABLET 24-26 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Entresto TABLET 49-51 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Entresto TABLET 97-103 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Methadone HCl TABLET 5 MG Oral

Update Quantity Limit #180/30 days

  3/15/2018

Methadone HCl TABLET 10 MG Oral

Update Quantity Limit #90/30 days

  3/15/2018

Methadone HCl CONCENTRATE 10 MG/ML Oral

Update Quantity Limit #90/30 days

  3/15/2018

Betaseron/Extavia KIT 0.3 MG SUBCUTANEOUS*

Add Quantity Limit #15/30 days

  3/15/2018

Dupixent Solution Prefilled Syringe 300 MG/2ML Subcutaneous

Add Quantity Limit #4/28 days

  3/15/2018

Apriso CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM ORAL

Add Quantity Limit #120/30 days

  3/15/2018

ValGANciclovir HCl SOLUTION RECONSTITUTED 50 MG/ML ORAL

Add Quantity Limit #6948/365 days

  3/15/2018

Invokana TABLET 100 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Jentadueto TABLET 2.5-1000 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Jentadueto TABLET 2.5-500 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Jentadueto TABLET 2.5-850 MG ORAL

Add Quantity Limit #60/30 days

  3/15/2018

Ilaris (150mg Delivered) SOLUTION RECONSTITUTED 180 MG Subcutaneous

Add Quantity Limit #2/30 days

  3/15/2018

 

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

 


Back