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Provider Notices

Pharmacy Coverage Updates Effective 09/15/2020

7/15/2020 5:06:19 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 09/15/2020.

Please review the summary of these changes below:

 

Drug Name

Change

Alternatives

Effective Date

Proair and Proair respiclick

Remove from formulary

 

Albuterol HFA, Ventolin HFA, Levalbuterol

09/15/2020

Novolog Flexpen Novolog Solution

Remove from formulary

 

Admelog, Insulin Lispro, Insulin Aspart

09/15/2020

Xopenex HFA

Remove from formulary

 

Albuterol HFA, Ventolin HFA, Levalbuterol

09/15/2020

Betamethasone Dipropionate ointment and cream

Add Quantity Limit of 90 grams per 30 days

 

09/15/2020

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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