MedicaidCoverageHigh impact
May 2026 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Endocrinology, Dermatology, Neurology +2 more·Prior Authorization
Effective date
May 15, 2026
We identified it
Apr 9, 2026
Summary
PacificSource Community Solutions (Medicaid) has removed 5 medications from formulary effective May 15, 2026 (Zostavax, Fycompa, Mavenciad, Bonjesta 20-20mg, Saxenda) and updated quantity limits for 5 medications including Freestyle Libre sensors and Yorvipath. Billing teams must immediately identify affected claims and implement prior authorization and coverage denials to prevent payment processing errors.
Action Required
By May 15, 2026: Billing team must update billing system to reflect formulary deletions for Zostavax, Fycompa, Mavenciad, Bonjesta 20-20mg, and Saxenda—all claims for these medications will be denied for PacificSource Community Solutions Medicaid members. Update quantity limits in system for Freestyle Libre 2 plus sensors (2/30 days), Freestyle Libre 3 plus sensors (2/30 days), Yorvipath 294 mcg (1.96/28 days), Yorvipath 168 mcg (1.12/28 days), and Opzelura cream (60/28 days). Front desk staff must educate providers to obtain prior authorization for any removed formulary drugs before service dates. Failure to implement these changes will result in claim denials and patient balance issues. Contact PacificSource Pharmacy Services at 888-437-7728 or 541-330-4999 for coverage questions.