Provider Notices


PacificSource Medical Drug Formulary changes, Effective on 01/01/2019

10/31/2018 9:12:01 AM

We are changing coverage of the following medications:

Effective on 01/01/2019 our formulary will change

 

Prior authorization will be required for the following medical codes 

Medical Drug Alternatives

Prescription Drug Alternative

Prescription Drug Alternative

Prescription Drug Alternative

J1453 

Emend (fosaprepitant) injection

 

 

 

 

 

Granisetron injection (J1626)

 

 

 

 

 

Ondansetron HCl Tablet 4 mg Oral

 

 

 

 

 

Ondansetron HCl Tablet 8 MG Oral

 

 

 

 

 

Ondansetron HCl TABLET 24 MG ORAL (quantity limit may apply)

J2469 

Aloxi (palonosetron hydrochloride) injection

C9463

Aprepitant injection (Cinvanti)

C9464

Rolapitant (Varubi)

J9315

Romidepsin (Istodax)

       

J7504

Antihymocyte Globulin Equine (Atgam)

       

J1575

Immune globulin/hyaluronidase, (Hyqvia)

       

J9328

Temozolomide injection

       

 

ACTION REQUIRED:

  • If you feel that the alternative medications included on the attached list are appropriate for your patient, please provide your patient with a new prescription. Some medications do not have alternatives. Please consult with your patient on the necessity of continuing this medication.

 

  • If you feel that it is medically necessary for your patient to continue this medical medication you may request a prior authorization. To request a prior authorization, please submit any pertinent documentation via the InTouch portal on our website or call us at:

 

Pharmacy Services Commercial (844) 877-4803

Pharmacy Government Services (888) 437-7728


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