Provider Notices


Pharmacy Coverage Updates Effective October 15, 2018

8/15/2018 8:41:46 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 October 15, 2018.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

Levorphanol Tartrate TABLET 2 MG ORAL

Remove, use OxyCODONE HCl Tablet, Morphine Sulfate TABLET, Oxymorphone HCl Tablet, HYDROmorphone HCl Tablet

10/15/2018

Bystolic TABLET

Remove, use atenolol, metoprolol, acebutolol, bisoprolol, betaxolol, propranolol, nadolol, pindolol, carvedilol

10/15/2018

Buprenorphine HCl SOLUTION 0.3 MG/ML Injection

Medical Benefit Only

10/15/2018

Alinia SUSPENSION RECONSTITUTED 100 MG/5ML ORAL

Add Quantity Limit 180mL (3 bottles) per 30 days

10/15/2018

Alinia TABLET 500 MG ORAL

Add Quantity Limit 6 tablets per 30 days

10/15/2018

Dexmethylphenidate HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG Oral

Update Quantity Limit to 30 tablets per 30 days

10/15/2018

Byetta 5 MCG Pen Solution Pen-injector 5 MCG/0.02ML Subcutaneous

Add Quantity Limit 1.2 mL (1 pen) per 30 days

10/15/2018

Byetta 10 MCG Pen Solution Pen-injector 10 MCG/0.04ML Subcutaneous

Add Quantity Limit 2.4 mL (1 pen) per 30 days

10/15/2018

Victoza Solution Pen-injector 18 MG/3ML Subcutaneous

Add Quantity Limit 9 mL (3 pens) per 30 days

10/15/2018

Trulicity Solution Pen-injector 1.5 MG/0.5ML Subcutaneous

Add Quantity Limit 2 mL (4 pens) per 28 days

10/15/2018

Testosterone 50 MG/5GM (1%) TRANSDERMAL

Add Quantity Limit 300 grams per 30 days

10/15/2018

Bonjesta Tablet Extended Release

20-20 MG Oral

Add Quantity Limit 60 tablets per 30 days

10/15/2018

Vancomycin HCl CAPSULE

Add Step Therapy authorization.  Consider using Firvanq.

10/15/2018

 

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 https://communitysolutions.pacificsource.com/Search/Drug.

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

 


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