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 November 15, 2024.
Summary of changes effective November 15, 2024
Change: Removed from formulary
- Myrbetriq
- Narcan nasal liquid
- Corlanor tablet
- Desenex 1% cream
- Aggrenox capsule
- Fer-In-Sol Solution 75 (15 Fe) MG/ML Oral
- Ferriprox 1000mg tablet
- Jadenu 180mg tablet
- Mifeprex 200mg tablet
- Millipred Solution 10 MG/5ML Oral
- Perforomist Nebulization Solution 20 MCG/2ML Inhalation
- Polytrim Solution 10000-0.1 UNIT/ML-% Ophthalmic
- Retin-A Cream 0.05 %
- Uceris Foam 2 MG/ACT Rectal
- Veripred 20 Solution 20 MG/5ML Oral
- Faslodex 250mg/5ml
- Endari packet
- Preparation 1% cream
- Relyvrio
- Ukoniq
- Exkivity
- Tegsedi
- Truseltiq
- Farydak
- Zorbtive
- Bynfezia
- Zejula capsule
Change: Update Quantity limit
- Clonidine TD weekly patch 0.1 mg/24hr; update quantity limit to 4/28
- Clonidine TD weekly patch 0.2 mg/24hr; update quantity limit to 4/28
- Clonidine TD weekly patch 0.3 mg/24hr; update quantity limit to 4/28
- Dexcom G6/G7 sensor; update quantity limit to 3/30
- Freestyle Libre sensors; update quantity limit to 2/28
- Omvoh; update quantity limit to 2/28
- Livmarli 9.5mg/ml; update quantity limit to 90/30
In addition to the above changes, we have updated the formulary to include a number of new medications that have been released in the past year. For a complete formulary listing, please visit our Find a drug: Medicaid page.
If you have questions regarding these changes, please contact your PacificSource Provider Service Representative or the PacificSource Pharmacy Services Team at 888-437-7728 or 541-330-4999.