Provider Notices

Pharmacy Coverage Updates Effective April 15, 2020 and June 15, 2020

3/17/2020 4:37:14 PM

We would like to inform you of changes to our PacificSource Community Solutions’ formulary and coverage policies. These changes are an amendment to previously scheduled changes.

We have recently updated our prior authorization list and coverage policies. These changes are effective for dates of service on or after April 15, 2020 and June 15, 2020.

Please review the summary of these changes below:

Drug Name

Change

Alternatives

Effective Date

Lantus solution

Lantus Solostar Pen

Remove from formulary

Basaglar Kwipen,

Tresiba Flextouch

04/15/2020

Levemir solution

Levemir Flextouch Pen

Remove from formulary

Basaglar Kwikpen

Tresiba Flextouch

4/15/2020

Canasa Rectal Suppositories

Remove from formulary

Generic formulation:

Mesalamine

6/15/2020

Lyrica Capsules

Remove from formulary

Generic formulation:

Pregabalin capsules

6/15/2020

Nuvaring

Remove from formulary

Generic formulations:

Eluryng, Etonogestrel-Ethinyl Estradiol

6/15/2020

Symbicort inhaler

Remove from formulary

Generic formulations:

Budesonide-formoterol inhaler

6/15/2020

Estrace Cream

Remove from formulary

Generic formulation:

Estradiol vaginal cream

6/15/2020

Hetlioz capsules

Remove from formulary

Not a covered benefit

6/15/2020

Jadenu 90mg

Jadenu 360mg

Remove from formulary

Generic formulation:

Deferasirox tablets

6/15/2020

Nebupent 300mg inhalation

Remove from formulary

Generic formulation:

Pentamidine isethionate inhalation

6/15/2020

Afinitor 2.5mg

Afinitor 5mg

Afinitor 7.5mg

Remove from formulary

Generic formulation:

Everolimus tablets

6/15/2020

Ofev capsules

Add quantity limit

#60 capsules / 30 days

 

6/15/2020

Albendazole 200mg tablets

Adjust quantity limit

#4 tablets/ 60 days

 

6/15/2020

Cimduo tablets

Temixys tablets

Add quantity limit

#30 tablets / 30 days

 

6/15/2020

Vancomycin capsules

Add quantity limit

125mg: #77/30 days

250mg: #38/30 days

 

6/15/2020

Lidocaine 5% ointment

Add quantity limit

#50 grams / 30 days

 

6/15/2020

 

 

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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