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Pharmacy Coverage Updates Effective March 1, 2023


We would like to inform you of changes to our PacificSource Medicare Advantage formulary and coverage policies.

We have recently updated our prior authorization list and coverage policies. These codes will now require Prior Authorization effective for dates of service on or after March 1, 2023.

Please review the summary of these changes below:

Drug Name



Q4081, J0885

In addition to the above changes, we have updated the formulary to include a number of new medications that have been released in the last year. For a complete formulary listing, please visit our Authorization Grid.

If you have questions regarding these changes, please contact your PacificSource Customer Service Representative (888) 863-3637.


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