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 May 15, 2026.
Summary of changes effective May 15, 2026
Change: Removed from formulary
- Zostavax
- Fycompa
- Mavenclad
- Bonjesta 20-20mg
- Saxenda
Change: Update Quantity Limit
- Freestyle Libre 2 plus sensors; Update quantity limit to 2/30
- Freestyle Libre 3 plus sensors; Update quantity limit to 2/30
- Yorvipath 294 mcg; Update quantity limit to 1.96/28
- Yorvipath 168 mcg; Update quantity limit to 1.12/28
- Opzelura cream; Update quantity limit to 60/28
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.