MedicaidCoverageHigh impact
November 2025 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Cardiology, Endocrinology, Hematology +2 more·Prior Authorization
Effective date
Nov 15, 2025
We identified it
Oct 6, 2025
Summary
PacificSource Community Solutions (Medicaid) has removed 7 medications from its formulary effective November 15, 2025: Brillinta 60mg tablet, Qsymia, Tasigna, Complera, Jynarque, Promacta tablets, Ixchiq, and Sandostatin LAR. Additionally, new medications released in the past year have been added to the formulary. Billing teams must identify patients on removed medications and coordinate with providers on alternative coverage options before the effective date.
Action Required
By November 14, 2025: Billing team must (1) query billing system for all active claims/encounters involving the 7 removed medications (Brillinta 60mg, Qsymia, Tasigna, Complera, Jynarque, Promacta tablets, Ixchiq, Sandostatin LAR) for PacificSource Community Solutions (Medicaid) members; (2) flag these claims for provider review to determine alternative medications or prior authorization appeals; (3) notify affected members and providers of the formulary changes; (4) update internal formulary reference documentation and billing software to reflect the removed medications as non-covered effective 11/15/2025. Contact PacificSource Provider Service Representative or Pharmacy Services Team (888-437-7728 or 541-330-4999) for guidance on prior authorization processes for therapeutic alternatives. Claims submitted after the effective date using removed medications will likely be denied as non-formulary unless prior authorization is obtained for medical necessity.