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Provider Notices

Pharmacy Coverage Updates Effective May 15, 2021

3/11/2021 3:15:41 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 May 15, 2021.

Please review the summary of these changes below:

Drug Name


Effective Date

Qutenza kit


Add prior authorization



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

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.


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