PacificSource Medical Drug Formulary changes, Effective on 01/01/2019
10/31/2018We are changing coverage of the following medications:
Effective on 01/01/2019 our formulary will change
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Prior authorization will be required for the following medical codes |
Medical Drug Alternatives |
Prescription Drug Alternative |
Prescription Drug Alternative |
Prescription Drug Alternative |
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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) |
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J2469 Aloxi (palonosetron hydrochloride) injection |
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C9463 Aprepitant injection (Cinvanti) |
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C9464 Rolapitant (Varubi) |
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J9315 Romidepsin (Istodax) |
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J7504 Antihymocyte Globulin Equine (Atgam) |
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J1575 Immune globulin/hyaluronidase, (Hyqvia) |
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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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