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Provider Notices

Pharmacy Coverage Updates Effective July 15, 2021

5/13/2021 5:27:53 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 July 15, 2021.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

 

Arcalyst solution

 

 

Add Quantity Limit

4 vials/28 days

7/15/2021

 

Inclusig 15mg


Update Quantity Limit

#30 tablets per 30 days

 

7/15/2021

 

Febuxostat 40mg

 

Add Quantity Limit

#90 tablets per 30 days

7/15/2021


Febuxostat 80mg

 

 

Add Quantity Limit

#30 tablets per 30 days

7/15/2021

Banzel Suspension

Remove Brand

(Generic available)

7/15/2021

Biktarvy

Add Quantity Limit

#30 tablets per 30 days

7/15/2021

Invokamet

 

Add Prior Authorization

 

7/15/2021

Ventolin HFA

Remove Brand

(Generic available)

7/15/2021

Proventil HFA

Remove Brand

(Generic available)

7/15/2021

Ferriprox Tablets 500mg

Remove Brand

(Generic available)

7/15/2021

 

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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