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Provider Notices

Pharmacy Coverage Updates Effective February 15, 2021

12/15/2020 3:00:13 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 February 15, 2021.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

 

Apriso 0.375gm capsules

 

 

Remove Brand

(Generic available)

2/15/2021

 

Truvada 200-300mg tablets


 

Remove Brand

(Generic available)

2/15/2021

 

Atripla 600-200-300 tablets

 

Remove Brand

(Generic available)

2/15/2021


Emtriva 200mg capsules

 

 

Remove Brand

(Generic available)

2/15/2021

Amicar 500mg tablets

Amicar 1000mg tablets

Remove Brand

(Generic available)

2/15/2021

Kuvan 100mg packet

Kuvan 500mg packet

Kuvan 100mg dispersible tablet

Remove Brand

(Generic available)

2/15/2021

Samsca 15mg tablets

Samsca 30mg tablets

Remove Brand

(Generic available)

2/15/2021

Symfi 600-300-300mg tablets

Symfi Lo 400-300-300 tablets

 

Remove Brand

(Generic available)

2/15/2021

Carafate suspension

Remove Brand

(Generic available)

2/15/2021

 

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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