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Provider Notices

Pharmacy Coverage Updates Effective October 15, 2022

9/8/2022 4:28:13 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 October 15, 2022.

Please review the summary of these changes below:

Drug Name

Change

Effective Date

 

Ruzurgi

 

 

Remove from Formulary

 

10/15/2022

Apokyn

 

Remove Brand from Formulary

 

10/15/2022

Daraprim

 

Remove Brand from Formulary

 

10/15/2022

 

Pyrimethamine tablets

 

Add Prior Authorization

 

10/15/2022

Nuedexta

Remove from Formulary

10/15/2022

Upneeq solution

Remove from Formulary

10/15/2022

 

Vascepa 1gm capsule

 

Remove Brand from Formulary

 

10/15/2022

 

Vimpat tablet and solution

 

Remove Brand from Formulary

 

10/15/2022

 

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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