Provider Notices


Pharmacy Coverage Updates Effective June 15, 2019

4/19/2019 8:43:15 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 June 15, 2019.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

Methylergonovine Maleate Tablet 0.2 MG Oral

Add Quantity Limit #120/365 days

6/15/2019

Albendazole Tablet 200 MG Oral

Add Quantity Limit #2/30 days

6/15/2019

Emverm Tablet Chewable 100 MG Oral

Update Quantity Limit to #6/28 days

6/15/2019

Quinine 324mg capsule

Add Quantity Limit #42/90 days

6/15/2019

Rivastigmine Tartrate CAPSULE 4.5 mg

Add Quantity Limit #60/30 days

6/15/2019

Rivastigmine Tartrate CAPSULE 6 mg

Add Quantity Limit #60/30 days

6/15/2019

Donepezil HCl TABLET 23 MG Oral

Add Quantity Limit #30/30 days

6/15/2019

Donepezil HCl Tablet Dispersible 10 MG Oral

Add Quantity Limit #30/30 days

6/15/2019

Donepezil HCl Tablet 10 MG Oral

Add Quantity Limit #30/30 days

6/15/2019

Rectiv Ointment 0.4 % Rectal

Not a Covered Benefit

6/15/2019

Topicaine 5 GEL 5 % EXTERNAL

Not a Covered Benefit

6/15/2019

Vibativ Solution Reconstituted 750 MG Intravenous

Medical Benefit Only

6/15/2019

Bees Wax WAX

Not a Covered Benefit

6/15/2019

Lactose Monohydrate POWDER

Not a Covered Benefit

6/15/2019

Sodium Chloride Bacteriostatic SOLUTION 0.9 % INJECTION

Medical Benefit Only

6/15/2019

Sorbitol SOLUTION 70 %

Not a Covered Benefit

6/15/2019

MethylPREDNISolone POWDER

Not a Covered Benefit

6/15/2019

 

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


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