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Provider Notices

Pharmacy Coverage Updates Effective January 1, 2022

12/1/2021 3:02:26 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 January 1, 2022.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

 

Epclusa tablets

 

 

Remove Brand

(generic available)

 

01/01/2022

Zepatier tablets

Remove from formulary

01/01/2022

 

Kybella

(J0591)

 

Add Prior Authorization

(Excluded benefit)

 

01/01/2022


Radiesse

(Q2026)

 

 

Add Prior Authorization

(Excluded benefit)

 

01/01/2022

 

Sculptra

(Q2028)

 

Add Prior Authorization

(Excluded benefit)

 

01/01/2022

 

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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