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Provider Notices

Medical Drug Formulary Change Effective 1/1/2021

10/29/2020 10:30:44 AM

Medical Drug Formulary Change Notification

This notification is to inform you of changes to our medical drug formulary.

Effective on 01/01/2021, our formulary prior authorization requirements will be updated. We are changing coverage of the following medications:

  • Liposomal Doxorubicin (Q2050)

  • Zoladex (J9202)

  • Marqibo (J9371)

  • Retisert (J7311)

  • Yutiq (J7314)

  • Krystexxa (J2507)

  • Vantas (J9225)

  • Varubi oral (J8670)

Actions may be required:

  • Some medications do not have alternatives. Please consult with your patient if continuing certain medications is necessary.

  • If it is medically necessary for your patient to continue with a current medication, you may request a prior authorization. To request a prior authorization, please submit any pertinent documentation via the InTouch portal www.PacificSource.com/AboutProviderInTouch/ or call us at (844) 877-4803 if you need assistance.


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