Does Pacificsource Community Health Plans require prior authorization for Valtoco 5 MG Dose Kit?
Pacificsource Community Health Plans does not require prior authorization for Valtoco 5 MG Dose Kit on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| {1 (0.1 ML) (diazepam 50 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 5 MG Dose Kit]2272630 | 11 / 11 | 0 | 0 | 11 | No prior authorization |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — {1 (0.1 ML) (diazepam 50 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 5 MG Dose Kit]
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| PacificSource Dual Care (HMO D-SNP) | H3864-043 | 4 | No | No | Yes |
| PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) | H3864-014 | 4 | No | No | Yes |
| PacificSource Medicare Essentials Choice Rx 36 (HMO-POS) | H3864-036 | 4 | No | No | Yes |
| PacificSource Medicare Essentials Rx 27 (HMO) | H3864-027 | 4 | No | No | Yes |
| PacificSource Medicare Essentials Rx 41 (HMO) | H3864-041 | 4 | No | No | Yes |
| PacificSource Medicare Essentials Rx 6 (HMO) | H3864-006 | 4 | No | No | Yes |
| PacificSource Medicare Explorer Rx 4 (PPO) | H4754-004 | 4 | No | No | Yes |
| PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) | H3864-024 | 4 | No | No | Yes |
| PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) | H3864-029 | 4 | No | No | Yes |
| PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) | H3864-034 | 4 | No | No | Yes |
| PacificSource Medicare MyCare Rx 40 (HMO) | H3864-040 | 4 | No | No | Yes |
- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
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Valtoco 5 MG Dose Kit at other payers
Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.