MedicaidCoverageHigh impact
Changes to our PacificSource Community Solutions formulary and coverage policies
PacificSource Health Plans·Oncology, Endocrinology, Rheumatology +1 more·Prior Authorization
Effective date
Jul 15, 2026
We identified it
Jun 10, 2026
Summary
PacificSource Community Solutions has removed 9 medications from their formulary effective July 15, 2026, including Pomalyst, Dificid, Invokana, Invokamet, Invokamet XR, Steglatro, Seglurometric, Jardiance, Prolia, and Xgeva. The policy also adds new medications released in the past year. Billing teams must identify claims for these removed drugs and implement denial protocols or seek alternative coverage pathways before the effective date.
Action Required
By July 14, 2026: Billing team must (1) update billing system to flag claims containing the 9 removed medications (Pomalyst, Dificid, Invokana, Invokamet, Invokamet XR, Steglatro, Seglurometric, Jardiance, Prolia, Xgeva) for PacificSource Community Solutions members; (2) implement denial protocols or prior authorization workarounds for dates of service on or after July 15, 2026; (3) notify providers in relevant specialties (oncology, endocrinology, rheumatology) to transition affected patients to alternative formulary medications before this date; (4) update encounter forms and EHR templates to reflect formulary changes. Contact PacificSource Provider Relations at 888-437-7728 or 541-330-4999 for clarification on specific member coverage options. Failure to update systems will result in claim denials for these medications.