Behavioral health criteria changing November 13, 2023
Beginning November 13, 2023, PacificSource will use different criteria for level-of-care decisions for mental health treatment (including inpatient, residential, partial...
Providers
December 2023 Drug List Change Notification (Commercial)
Updates on Existing Criteria
December 2023. The following changes to criteria are effective December 22, 2023:
Prior Authorization Criteria – Clinical Updates...
Pharmacy coverage updates effective November 15, 2023 (Medicaid)
We have recently updated our prior authorization list and coverage policies. This change is effective for dates of service on or after November...
ABA treatment services and neuropsychological and psychological testing will require prior authorization
New prior authorization requirements for providers regarding certain behavioral health services
Humira coverage is changing for Medicaid members
Here’s what you need to know:
Coverage of Humira (adalimumab) through PacificSource Community Solutions will change to other, biosimilar formulations.
Will I still be able to prescribe Humira?...
Stay extensions available for members in skilled nursing facilities (Medicaid)
PacificSource Community Solutions (Medicaid) allows a 20-day skilled nursing facility (SNF) stay for individuals who qualify for skilled care. Prior authorization is not required for admission to a...
Behavioral Health treatment plans required in 2024
Effective January 1, 2024, PacificSource will begin completing utilization management reviews for members who have received 26 or more therapy/counseling...
November 2023 Drug List Change Notification (Commercial)
Updates on Existing Criteria
November 2023. The following changes to criteria are effective November 22, 2023:...
Trigger finger or thumb surgical procedure will require prior authorization effective November 1, 2023
For Medicaid plans: Effective November 1, 2023, a prior authorization will be required for CPT Code 26055 (Tendon Sheath Incision).
Fractional laser treatment will require prior authorization
For commercial plans (individual and group), fractional laser treatment (codes 0479T and 0480T) will require prior authorization effective November 1, 2023.