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 March 15, 2022.
Please review the summary of these changes below:
|
Drug Name |
Change |
Effective Date |
|---|---|---|
|
Annovera (J7294) |
Add Prior Authorization
|
03/15/2022 |
|
(J7295)
|
Add Prior Authorization
|
03/15/2022 |
|
Sustol (J1627) |
Add Prior Authorization
|
03/15/2022 |
|
Epinephrine solution auto-injector |
Add Quantity Limit #4 pens per 90 days |
3/15/2022 |
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