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Provider Notices
Pharmacy Coverage Updates Effective August 15, 2020
6/15/2020 5:24:32 PMWe 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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