MedicaidCoverageHigh impact
January 2026 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Rheumatology, Gastroenterology, Infectious Disease·Prior Authorization
Effective date
Jan 15, 2026
We identified it
Dec 8, 2025
Summary
PacificSource Community Solutions (Medicaid) removed three medications from formulary effective January 15, 2026: Xifaxan, Actемra ACTpen, and Actемra prefilled syringe. Billing teams must identify claims for these drugs and implement denial protocols or alternative medication routing for affected Medicaid members.
Action Required
By January 15, 2026: Billing team must update PacificSource Community Solutions (Medicaid) claim submission system to identify and flag any claims for Xifaxan, Actемra ACTpen, or Actемра prefilled syringe—these will no longer be covered. Notify providers in affected specialties (rheumatology, gastroenterology, infectious-disease) immediately to ensure they have alternative medication options documented before the effective date. Update prior authorization protocols to reflect formulary removal. Implement denial reason codes in billing software for any claims submitted for these three drugs on or after January 15, 2026. Contact PacificSource Provider Service Representative at 888-437-7728 or 541-330-4999 with coverage questions. Failure to identify these claims pre-billing will result in claim denials and patient billing issues.