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, 2025.
Summary of changes effective September 15, 2025
Change: Removed from formulary
- Brilinta 90mg tablet
- Xarelto 2.5mg tablet
- Entresto tablet
- Advate
- Hemlibra
- Jivi
- Novoseven
- Rixubis
- Kogenate FS
- Idelvion
- Hemofil M
- Esperoct
- Alprolix
- Alphanate/VWF
- Humate-P
- Koate-DVI
- Monoclate-P
- Recombinate
- Xyntha kit
- Alhemo
- Alphanine SD
- Mononine
- Obizur
- Sevenfact
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.