MedicaidCoverageHigh impact
September 2025 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Cardiology, Hematology, Internal Medicine·Prior Authorization
Effective date
Sep 15, 2025
We identified it
Aug 4, 2025
Summary
PacificSource Community Solutions (Medicaid) is removing 29 medications from formulary effective September 15, 2025, including anticoagulants (Brillinta, Xarelto, Entresto) and clotting factor replacements (Advate, HemLibra, Jivi, and others). The plan has also added new medications released in the past year. Billing teams must identify patients on removed medications and coordinate with providers for alternative coverage or prior authorization pathways before the effective date.
Action Required
By September 14, 2025: (1) Billing team must identify all active patients on PacificSource Community Solutions Medicaid with claims history for the 29 removed medications (Brillinta 90mg, Xarelto 2.5mg, Entresto, Advate, HemLibra, Jivi, Novoseven, Rixubis, Kogenate FS, Idelvion, Hemofil M, Esperoctol, Alprolixol, Alphanate/VWF, Humate-P, Koate-DVI, Monoclate-P, Recombinate, Xyntha kit, Alhemo, Alphanine SD, Mononine, Obizur, Sevenfact). (2) Clinical staff and providers must contact patients and prescribers to arrange alternative medications or appeal for coverage exceptions before September 15. (3) Update billing system rules to flag these 29 medications as non-covered for this plan effective September 15. (4) Brief front desk and authorization staff that claims for these medications submitted after September 15 will be denied unless prior authorization is obtained through appeals process. (5) Direct patients/providers to PacificSource Provider Service Representative or Pharmacy Services Team (888-437-7728 or 541-330-4999) for formulary questions and prior authorization options. Failure to act will result in claim denials and service disruptions for affected patients.