Observation Stays No Longer Subject to Concurrent Review

Upcoming Authorization Requirement Changes

Monday, November 3, 2014

FirstCare Health Plans will update its authorization requirements for 2015.  Below is a summary of upcoming changes to our Prior Authorization Matrix:

Medical Pharmacy Update

An updated medical pharmacy list can be found here, and it includes all medications that currently require prior authorization, as well as new additions which will go into effect as of February 1, 2015.

  • Note: This list applies to medications covered under FirstCare’s medical benefit. For medications obtained through the FirstCare pharmacy benefit, please refer to the appropriate drug list for the members plans:  HMO/PPOMedicaidMedicare

Prior Authorization Matrix Changes

Effective December 1, 2014, some authorization requirements have been removed from our Prior Authorization Matrix, including:

  • Hip Arthroscopy
  • Hospice Services
  • LEAP
  • Neuropsychological Testing
  • Tonsillectomy and Adenoidectomy (no authorization required for ages 12 and under)
  • Wound Care (basic wound care only—specialty dressings/services may still require authorization) 

FirstCare will add requirements to Prior Authorization Matrix, effective for dates of service on or after February 1, 2015 for the following services:

  • Spinal Procedures (Laminectomy/Fusion)
  • Ventricular Assist Devices
  • Varicose Vein Procedures (category updated, new codes added)

If you have questions, please contact your Provider Relations Representative at the number below:
  • Abilene area (1-325-670-3525)
  • Amarillo area (1-800-239-5650)
  • Lubbock area (1-806-784-4380)
  • All other areas (1-800-431-7737)

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