2015 Summary of Changes 2015 Prior Authorization List and Utilization Guidelines Midyear update: July 1, 2015 Community Health Plan of Washington is accountable for our members’ safety and ensures appropriate care. Based on semi-annual reviews of utilization data, changes to the PA list are made. It is important that both the provider and the health plan work in partnership to ensure appropriate care for those we serve. Below is a summary of the changes to the Prior Authorization List and Utilization Guidelines from 2014 to 2015. Please refer to the complete 2015 Prior Authorization List and Utilization Guidelines for all the services that require prior authorization. Removed from Prior Authorization List Category: Surgical Procedures: Injectable Drugs: Page 1 of 2 Specific Service: Cataract Procedures Knee Arthroscopy Shoulder Arthroscopy Urethral Suspensions Uvulopalatopharyngoplasty Alpha-1-Proteinase inhibitor Amifostine Belimumab C1 Esterase inhibior Canakinumab Certolizuman Docetaxel Epoprostenol Golimumab Etanercept Icatibant Acetate Iloprost Peginesatide Pertuzumab Rilonacept Updated: 5/2015 2015 Summary of Changes 2015 Prior Authorization List and Utilization Guidelines Midyear update: July 1, 2015 Changes to existing requirements Category: Unlisted Codes: Added to Prior Authorization List Category: Mental Health: Injectable Drugs: Surgical Procedures: Home Health Services and Inpatient Services: Mental Health: Mental Health: Radiology: Radiology: Radiology: Page 2 of 2 Specific Service: Unlisted codes with a charge greater than $500 require Prior Authorization. This is a decrease from the $1000 limit in 2014. Specific Service: Applied Behavioral Analysis Aflibercept Facet Neurotomy Hospice Services Electroconvulsive Therapy Repetitive Transcranial Magnetic Stimulation (rTMS) Dual X-ray Absorptiometry Proton Beam Radiation Therapy Intensity Modulated Radiation Therapy