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Provider Notices

Pharmacy Coverage Updates Effective August 15, 2020

6/15/2020 5:24:32 PM

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 August 15, 2020.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

Daptomycin injection

J0878

Add prior authorization

8/15/2020

Cocaine 4% solution

Remove from formulary

8/15/2020

Clindamycin 1% solution

Add quantity limit

 #240mL per 30 days

8/15/2020

Cephalexin 750mg capsules

Remove from formulary

8/15/2020

Zontivity

Add quantity limit

#30 per 30 days

8/15/2020

Clobazam tablets

Add quantity limit

10mg tablets #120 per 30

20mg tablets #60 per 30 days

8/15/2020

 

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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