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Search Tips

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• Make sure you've entered the correct spelling of the drug name
• If you're not sure how to spell the drug, you can type just the first few letters of the name (for a broader search).
• Still stuck? Please contact Customer Service to confirm if your drug is not covered. If you learn that PacificSource Medicare does not cover your drug, you can ask Customer Service for a list of similar drugs that are covered.

Non-Formulary Drug Explanation

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If your search results indicate non-formulary, your drug may not be on the formulary or may be excluded from coverage. If your drug is not listed, please contact Customer Service to confirm if your drug is not covered. If you learn that PacificSource Medicare does not cover your drug, you can ask Customer Service for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered.

Your Rights

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You and your doctor have the right to request an exception to the plan’s formulary or coverage criteria. If you would like to request an exception, please contact the PacificSource Medicare Customer Service Department.

How do I change my prescription?

If your drug is not on our formulary you can ask us if we cover another drug used to treat your medical condition. If we cover another drug for your condition, we encourage you to ask your doctor if these drugs that we cover are an option for you. If your doctor tells you that none of the drugs we cover for treating your condition is medically appropriate, you have the right to request an exception from us to cover the drug that was originally prescribed.

How do I request an exception?

The first step in requesting an exception to our coverage rules is for you to ask your prescribing doctor to contact us.

Your doctor must submit a statement supporting your request. It may be helpful to take this notice with you to the doctor or submit it to his or her office. The doctor’s statement must indicate that the requested drug is medically necessary for treating your condition, because none of the drugs on our formulary would be as effective as the requested drug or would have adverse effects for you. If the exception request involves a prior authorization, quantity limit, or other limit we have placed on a formulary drug, the doctor's statement must indicate that the prior authorization, or limit, would not be appropriate given your condition or would have adverse effects for you.

Once the physician's statement is submitted, we must notify you of our decision no later than 24 hours, if the request has been expedited, or no later than 72 hours, if the request is a standard request. Your request will be expedited if we determine, or your doctor informs us, that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.