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Provider Notices

Pharmacy Coverage Updates Effective December 15, 2020

10/14/2020 3:06:27 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 December 15, 2020.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

Corlanor

 

Add QL of 60 tablets per 30 days

450 mls/30 days

12/15/2020

 

Simponi SQ

                       

 


Remove from formulary

 

 

12/15/2020

 

Taltz

 

 

Remove from formulary

 

12/15/2020

 

Palforzia

 

Remove from formulary

 

12/15/2020

 

Doxycycline monohydrate capsules

 

Remove 75mg and 100mg from formulary

 

12/15/2020

 

Doxycyline Hyclate tablets

 

Remove 50mg and 100mg from formulary

 

12/15/2020

 

Tecfidera

 

Remove brand name product from formulary (generic available)

 

12/15/2020

 

Jardiance

Invokana

 

Move from step therapy to prior authorization

 

12/15/2020

 

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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