What types of policy changes does PacificSource Health Plans issue?

PacificSource Health Plans regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does PacificSource Health Plans update its policies?

PacificSource Health Plans typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many PacificSource Health Plans policy changes are tracked here?

This page currently tracks 27 documented PacificSource Health Plans policy changes. New items are added as they are identified.

What should I do when PacificSource Health Plans changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

PacificSource Health Plans Policy Changes & Prior Auth Updates

We track 27 documented policy changes from PacificSource Health Plans across ID, MT, OR, WA. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original PacificSource Health Plans notice. Use the related links below to narrow results by specialty or state, or sign up for a free daily alert to receive new PacificSource Health Plans updates automatically.

High impact
Hospital observation services: billing and reimbursement policy updates
PacificSource Health Plans·Effective Jul 1, 2026
PacificSource is implementing new billing and reimbursement requirements for hospital observation services effective July 1, 2026. HCPCS code G0378 must be billed with revenue code 0762 on a single claim line with units representing total observation hours (minimum 8 hours required), and must be paired with specific qualifying services. G0379 may only be used for direct admissions without concurrent ED, clinic, or critical care services.
High impact
Changes to our PacificSource Community Solutions formulary and coverage policies
PacificSource Health Plans·Effective Jul 15, 2026
PacificSource Community Solutions has removed 9 medications from their formulary effective July 15, 2026, including Pomalyst, Dificid, Invokana, Invokamet, Invokamet XR, Steglatro, Seglurometric, Jardiance, Prolia, and Xgeva. The policy also adds new medications released in the past year. Billing teams must identify claims for these removed drugs and implement denial protocols or seek alternative coverage pathways before the effective date.
High impact
August 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective Aug 22, 2026
PacificSource is making significant formulary changes effective August 22, 2026, adding 20+ new drugs to the commercial formulary (mostly tier 2-3 with prior authorization requirements), removing 3 drugs, and updating prior authorization criteria for multiple drug classes including CFTR modulators, ETA receptor antagonists, hereditary angioedema treatments, and oncology agents. State-based plans (OR, ID, MT, WA) have different formulary placements and removals. Billing teams must update systems to enforce new prior auth requirements and quantity limits.
Low impact
PacificSource Welcomes Community to PACE Open House
PacificSource Health Plans·Effective Jul 1, 2026
PacificSource is launching a new PACE (Program of All-Inclusive Care for the Elderly) program in Lane County, Oregon, with an official grand opening on July 1, 2026. This is a new Medicare service offering for adults 55+ with complex medical and social needs, requiring billing teams to understand eligibility, referral processes, and potential billing implications for PACE-covered services.
High impact
June 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective Jun 22, 2026
PacificSource is implementing major formulary and prior authorization changes effective June 22, 2026, including 16 new drug additions across multiple tiers, removal of 5 standalone policies consolidated into broader categories, and state-specific formulary removals for OR/ID/MT/WA members. Billing teams must update systems to reflect new prior authorization requirements, quantity limits, step therapy rules, and limited access restrictions across numerous medications.
High impact
May 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective May 22, 2026
PacificSource updated its commercial drug formulary effective May 22, 2026, adding 10 new medications with tier 3 (or tier 4 in OR/ID/MT/WA) designations and various restrictions including prior authorization, quantity limits, and step therapy requirements. The update also retired the Fibrates policy due to drug discontinuation, modified prior authorization criteria for 13 drug classes, and removed 4 drugs from the formulary (Acyclovir solution, Megace ES suspension, Sitavig tablet, Triglide tablet).
High impact
May 2026 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Effective May 15, 2026
PacificSource Community Solutions (Medicaid) has removed 5 medications from formulary effective May 15, 2026 (Zostavax, Fycompa, Mavenciad, Bonjesta 20-20mg, Saxenda) and updated quantity limits for 5 medications including Freestyle Libre sensors and Yorvipath. Billing teams must immediately identify affected claims and implement prior authorization and coverage denials to prevent payment processing errors.
High impact
April 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective Apr 9, 2026
PacificSource is implementing significant changes to GLP-1 receptor agonist prior authorization criteria, adding Tofidence as a tier 3 formulary drug with medical necessity requirements, updating quantity limits for Journavx Nurtec, and adding formulary exception criteria for Nurtec tablet across commercial plans and state-based drug lists (OR, ID, MT, WA). All changes are effective April 9, 2026.
High impact
Prior authorization changes for February 1, 2026 – Medicare and Medicaid
PacificSource Health Plans·Effective Feb 1, 2026
Effective February 1, 2026, PacificSource is implementing new prior authorization requirements for Medicare and Medicaid. Medicare adds 20 procedure codes requiring prior auth (including arthroscopy, unlisted procedures, and specialized diagnostics) plus 3 codes requiring prior auth only when claims exceed $500. Medicaid adds 2 codes requiring prior auth. Billing teams must update systems and verify all affected codes before service delivery to avoid claim denials.
High impact
January 2026 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Effective Jan 15, 2026
PacificSource Community Solutions (Medicaid) removed three medications from formulary effective January 15, 2026: Xifaxan, Actемra ACTpen, and Actемra prefilled syringe. Billing teams must identify claims for these drugs and implement denial protocols or alternative medication routing for affected Medicaid members.
High impact
Medicaid and Commercial Prior Authorization Changes
PacificSource Health Plans·Effective Jan 1, 2026
Effective January 1, 2026, both Commercial and Medicaid plans are implementing new prior authorization requirements for specific CPT/HCPCS codes. Additionally, certain HCPCS codes for Medicaid require prior authorization only when item costs exceed $500. The billing team must identify affected codes and implement authorization workflows before services are rendered.
High impact
Medicaid Peer delivered services policy update
PacificSource Health Plans·Effective Jan 1, 2026
PacificSource Medicaid is updating its peer-delivered services policy effective January 1, 2026. Providers billing more than 8 units of peer-delivered services must now submit clinical documentation with claims to establish medical necessity and appropriateness. Claims exceeding 8 units submitted without documentation will be denied.
High impact
Pharmacy prior authorization extension notification
PacificSource Health Plans·Effective Dec 23, 2025
PacificSource has extended prior authorization approval date ranges for specific maintenance medications and medical benefit drugs, effective immediately. Commercial members receive 5-year extensions while Medicaid members receive 1-year extensions. Billing teams must verify updated authorization dates in the InTouch for Providers portal to avoid claim denials.
High impact
November 2025 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Effective Nov 15, 2025
PacificSource Community Solutions (Medicaid) has removed 7 medications from its formulary effective November 15, 2025: Brillinta 60mg tablet, Qsymia, Tasigna, Complera, Jynarque, Promacta tablets, Ixchiq, and Sandostatin LAR. Additionally, new medications released in the past year have been added to the formulary. Billing teams must identify patients on removed medications and coordinate with providers on alternative coverage options before the effective date.
High impact
October 2025 Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective Oct 22, 2025
PacificSource is implementing significant changes to prior authorization criteria and preferred drug list (PDL) formulary effective October 22, 2025. This includes updates to 25+ drug policies (adding new medications, removing coverage for others, and changing clinical criteria), 40+ new formulary additions with specialty pharmacy and quantity limits, and removal of 50+ older medications from coverage. Billing teams must immediately identify which medications their patients use and verify coverage status, prior authorization requirements, and tier placement before claims are submitted.
High impact
Montana State Based Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective Oct 1, 2025
PacificSource Montana Commercial plans are removing prior authorization requirements and formulary coverage for 60+ medications effective October 1, 2025, spanning hormone therapies, respiratory, diabetes, and specialty drugs. Billing teams must immediately update systems to stop requiring prior authorizations for these medications and verify patient coverage status, as claims submitted with unnecessary prior auth requests may be denied or delayed.
High impact
September 2025 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Effective Sep 15, 2025
PacificSource Community Solutions (Medicaid) is removing 29 medications from formulary effective September 15, 2025, including anticoagulants (Brillinta, Xarelto, Entresto) and clotting factor replacements (Advate, HemLibra, Jivi, and others). The plan has also added new medications released in the past year. Billing teams must identify patients on removed medications and coordinate with providers for alternative coverage or prior authorization pathways before the effective date.
Medium impact
Idaho 2026 Individual & Family Rate Changes
PacificSource Health Plans·Effective Jan 1, 2026
Idaho health plan rates for individual and family coverage are increasing in 2026. The policy references a justification document explaining the rate increase reasons, but specific rate percentages, affected plan names, and implementation details are not provided in this announcement. Billing teams should review the full justification PDF for complete information.
Medium impact
Medicaid Grievance and Appeals policies
PacificSource Health Plans·Effective Jun 25, 2025
PacificSource has updated its Medicaid Grievance and Appeals policies effective June 25, 2025. The policy provides guidance on grievance procedures, appeals processes, member education requirements, and notices of adverse benefit determinations. Billing teams must ensure claims processes align with these new member communication and appeal notification requirements.
Medium impact
February 2026 Drug List Change Notification (Commercial)
PacificSource Health Plans·Identified Dec 19, 2025
Failed to analyze policy change
Medium impact
December 2025 Drug List Change Notification (Commercial)
PacificSource Health Plans·Identified Oct 20, 2025
Failed to analyze policy change
Low impact
Agreement reached with OHSU network
PacificSource Health Plans·Effective Apr 2, 2026
PacificSource has successfully negotiated and reached a two-year agreement with OHSU (Oregon Health and Science University) effective April 2, 2026. OHSU remains in the PacificSource network for both Medicare and Commercial members with no changes to coverage, access to care, or existing authorizations. This resolves the termination notice issued on March 10, 2026, and billing operations should continue unchanged.
Low impact
Continued access to care through St. Charles & Salem Health for Commercial and Medicare Members
PacificSource Health Plans·Effective Jan 1, 2026
PacificSource has secured continued in-network agreements with St. Charles Health System and Salem Health Hospitals & Clinics for Commercial and Medicare plans in 2026 (and 2027 for St. Charles Commercial). No coverage or provider access changes for Commercial and Medicare members—billing teams should take no action as claims processing workflow remains unchanged. Note: Medicaid coverage with Salem Health is still under negotiation.
Low impact
Continued access to care through St. Charles Health System
PacificSource Health Plans·Effective Jan 1, 2026
PacificSource has secured network agreements with St. Charles Health System for Commercial plans (2026-2027) and Medicare plans (2026). No billing workflow changes are required—St. Charles providers remain in-network, and member coverage and access continue unchanged.
Low impact
Stronger security for InTouch and the myPacificSource app
PacificSource Health Plans·Effective Aug 15, 2025
PacificSource is implementing enhanced security measures for InTouch member portal and myPacificSource app, effective mid-August 2025. Members will be required to update credentials one-time and subsequently authenticate via multi-factor authentication (text/call with numeric codes) at each login. This is an operational/administrative change affecting member portal access, not billing codes or clinical procedures.
Low impact
Mental Health Is Health: Practical Support for Our Community
PacificSource Health Plans·Identified May 18, 2026
This is a community awareness and advocacy message from PacificSource emphasizing mental health as integral to overall healthcare. It does not introduce billing changes, new coverage policies, prior authorization requirements, or specific clinical guidance that would affect claims processing or billing workflows.
Low impact
2025 Fall Provider Workshops
PacificSource Health Plans·Identified Jul 24, 2025
PacificSource is hosting annual Provider Workshops in October 2025 to inform providers about policy updates, new tools, initiatives, and plan changes for 2025. This is an informational announcement about educational events with no direct billing or coding changes for the practice.

PacificSource Health Plans in ID PacificSource Health Plans in MT PacificSource Health Plans in OR PacificSource Health Plans in WA PacificSource Health Plans: Allergy & Immunology PacificSource Health Plans: Cardiology PacificSource Health Plans: Cardiothoracic Surgery PacificSource Health Plans: Critical Care All payers

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Hospital observation services: billing and reimbursement policy updates

Changes to our PacificSource Community Solutions formulary and coverage policies

August 2026 Drug List Change Notification (Commercial)

PacificSource Welcomes Community to PACE Open House

June 2026 Drug List Change Notification (Commercial)

May 2026 Drug List Change Notification (Commercial)

May 2026 Community Solutions (Medicaid) formulary and coverage policies notification

April 2026 Drug List Change Notification (Commercial)

Prior authorization changes for February 1, 2026 – Medicare and Medicaid

January 2026 Community Solutions (Medicaid) formulary and coverage policies notification

Medicaid and Commercial Prior Authorization Changes

Medicaid Peer delivered services policy update

Pharmacy prior authorization extension notification

November 2025 Community Solutions (Medicaid) formulary and coverage policies notification

October 2025 Drug List Change Notification (Commercial)

Montana State Based Drug List Change Notification (Commercial)

September 2025 Community Solutions (Medicaid) formulary and coverage policies notification

Idaho 2026 Individual & Family Rate Changes

Medicaid Grievance and Appeals policies

February 2026 Drug List Change Notification (Commercial)

December 2025 Drug List Change Notification (Commercial)

Agreement reached with OHSU network

Continued access to care through St. Charles & Salem Health for Commercial and Medicare Members

Continued access to care through St. Charles Health System

Stronger security for InTouch and the myPacificSource app

Mental Health Is Health: Practical Support for Our Community

2025 Fall Provider Workshops