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Pharmacy Coverage Updates Effective September 15, 2023

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 September 15, 2023.

Summary of changes effective September 15, 2023

Change: Now requiring prior authorization

  • Emverm

Change: Removed from formulary

  • Esbriet
  • Nityr
  • Nexavar
  • Targretin 1% gel
  • Naftin gel
  • Prezista 600mg, 800mg tablet
  • Zavesca
  • Iressa
  • Noxafil suspension
  • Aubagio
  • Tresiba
  • Humira

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.