Medical Policy, Reimbursement Policy, Pharmacy Policy, & Provider Information
Providence Health Plan, Providence Health Assurance, and Providence Health Plan Partners
Select a topic below to access policies or more information:
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Prior-authorization, Non-covered, and DME and Supplies Lists and Fax Forms
The following lists are intended to provide guidance regarding coverage of healthcare services and are not all inclusive. Additional exclusions may apply based on benefit and contract terms.
Please see the “Pharmacy Policies” section below for information regarding drugs that require authorization.
General Prior-authorization Requirements
- General PA Requirements Medicare HMO
- General PA Requirements PEBB Statewide and PEBB Choice
- General PA Requirements PPO
- General PA Requirements Standard
- General PA Requirements PHS Swedish, Kadlec, PacMed
- General PA Requirements OHP
- General PA Requirements YCCO
“Due to recent scheduling issues associated with the COVID19 pandemic, providers and members may call the prior authorization team at 503-574-6400 and request for an extension of approved prior authorization if services have not been rendered. Eligibility and benefits at time of service still apply. Thank you.”
Effective March 1, 2023, American Imaging Management/AIM Specialty Health and Beacon Health Options changed their names to Carelon. AIM transitioned to Carelon Medical Benefits Management, and Beacon Health Options transitioned to Carelon Behavioral Health. If you have questions about this change, please call 800-878-4445 or click here to learn more.
Prior-authorization Medical Fax Form
Prior-authorization Pharmacy Fax Form
Prior-authorization Behavioral Health Fax Forms
For new members, authorizations will be held until member eligibility can be verified.
- Prior authorization Facility based BH (Inpatient, Residential, Partial Hospital, and IOP PA) Form
- Prior Authorization BH Outpatient Fax Form
- Prior Authorization BH TMS Fax Form
- Prior Authorization BH ABA Fax Form
Clinical Edit Inquiry Form
Clinical Edit Inquiry Form instructions
**Before sending in a Clinical Edit Inquiry form, review all applicable Payment Policies and Medical Director Edits.
This form can be completed by participating providers.
- Completely fill out the ‘Sender information’ box at the top of the form.
- Include the following as instructed on the form:
- Chart notes for date of service that support all procedures.
- Letter of explanation for the inquiry
- Check the box to identify which edit is being appealed. If the edit you are appealing is not listed, enter the edit code in the blank box.
- Pay close attention to which fax number is listed above the edit code that applies to ensure that the form is sent to the correct area.
Non- participating providers that are disputing a clinical edit would need to send information to the claim support team fax # 503-574-8146
eviCore High Tech Imaging Prior Authorization Code List
- eviCore High Tech Imaging Prior Authorization Code List - August 2023
- eviCore High Tech Imaging Prior Authorization Code List - April 2023
- eviCore High Tech Imaging Prior Authorization Code List - March 2023
- eviCore High Tech Imaging Prior Authorization Code List - January 2023
- eviCore High Tech Imaging Prior Authorization Code List - December 2022
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Coding Policies and Alerts
Billing, Payment, and Coding Policy Alerts
- Coding Policy Alert July/August 2023
- Coding Policy Alert May/June 2023
- Coding Policy Alert March/April 2023
- Coding Policy Alert January/February 2023
- Coding Policy Alert - Special Edition - December 2022
- Coding Policy Alert November/December 2022
- Coding Policy Alert September/October 2022
- Coding Policy Alert July/August 2022
- Coding Policy Alert May/June 2022
- Coding Policy Alert March/April 2022
- Coding Policy Alert January/February 2022
- Coding Policy Alert September/October 2021
- Coding Policy Alert July/August 2021
- Coding Policy Alert May/June 2021
- Coding Policy Alert March/April 2021
- Coding Policy Alert January/February 2021
- Coding Policy Alert November/December 2020
- Coding Policy Alert October 2, 2020
- Coding Policy Alert September/October 2020
- Coding Policy Alert July/August 2020
- Coding Policy Alert June 26, 2020
- Coding Policy Alert April 2, 2020
- Coding Policy Alert March 26, 2020
- Coding Policy Alert March/April 2020
- Payment and Coding Policy Alerts – COVID-19 UPDATE
- Telehealth Services DURING COVID-19 CRISIS
Billing, Payment, and Coding Policies
- 01.0 Coding Policy Development
- 03.0 Assistant for Surgical Procedures
- 04.0 Procedure Specific Policies
- 05.0 Incidental and Mutually Exclusive Surgical Procedures
- 06.0 Multiple Surgery
- 07.0 Global Payment for Obstetrical Care DURING COVID-19 CRISIS
- 08.0 Duplicate Diagnostic Test Interpretations
- 09.0 Anesthesia
- 10.0 Modifier -22
- 11.0 Place of Service for Diagnostic Services
- 12.0 Global Surgical Package
- 13.0 Bundled or Adjunct Services
- 14.0 Bilateral Procedures
- 16.0 Co-Surgeons
- 17.0 Routine Vision Benefit for Medicare Advantage
- 18.0 Venipuncture
- 19.0 Service Code Policy
- 20.0 Split Global Surgical Package
- 22.0 HCPCS S-Codes
- 27.0 Billing Guidelines for New or Unlisted Codes
- 28.0 Urine Drug Testing
- 29.0 Date of Service for Professional Claims
- 30.0 Lab Panel Billing
- 31.0 Modifier -25
- 32.0 Modifier -57
- 33.0 Modifier 59 and Other Modifiers for Distinct Procedural Services
- 34.0 Administration of Immunizations and Injections
- 35.0 Laboratory Services, Professional Charges
- 38.0 Outpatient Supplies
- 39.0 Modifiers -73 and -74
- 40.0 Mid-Level Practitioners
- 41.0 Multiple Endoscopy
- 42.0 Modifiers GA, GY, and GZ
- 44.0 Facility Take Home Items
- 50.0 Modifier -63
- 51.0 Modifier 47
- 52.0 Medical Visits
- 53.0 Online Digital Evaluation and Management Services FOR COVID-19 PHE
- 55.0 Medicare Diabetes Prevention Program
- 57.0 Modifiers -52 and -53
- 58.0 Documentation Guidelines for Medical Services
- 60.0 Documentation Guidelines Amended Notes
- 62.0 Incident To DURING COVID-19 PHE
- 63.0 Web-Based Dermatology Consultation for Review of Images
- 64.0 Opioid Treatment Programs
- 65.0 Guidelines for Billing Consultations
- 67.0 Telemedicine Services REQUIRING ORIGINATING SITE
- 67.0.A MEDICARE Telehealth Services DURING COVID-19 PHE
- 67.0.B COMMERCIAL OREGON PROVIDERS Telehealth Services DURING COVID-19 PHE
- 67.0.C OHP Telehealth Services DURING COVID-19 PHE
- 67.0.D COMMERCIAL WASHINGTON PROVIDERS Telehealth Services DURING COVID-19 PHE
- 67.0.E NONMEDICARE Telemedicine Services During COVID-19 PHE.
- 68.0 Limited Comparative Radiographic Exams
- 70.0 Locum Tenens or Reciprocal Billing
- 71.0 Modifiers SH and SJ
- 72.0 Modifiers 58, 78, 79
- 74.0 ASC Payment Structure
- 78.0 Reasonable Billing Practices
- 85.0 Therapy Services
- 86.0 Palliative Care
- 88.0 APC Payment Methodology
- 89.0 Intraoperative Monitoring
- 90.0 Chemotherapy Administration
- 92.0.PHE Telephone Services FOR COVID-19 PHE
- 95.0 Codes with TC and PC for Services Performed in Facilities
- 98.0 Advance Care Planning
- 99.0 Radiology Multiple Procedure Reduction
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Medical, Reimbursement, and Pharmacy Policy Alerts
Medical and Pharmacy Policy Alerts
- Special Alert September 2023 - Inpatient Readmissions
- September 2023
- August 2023
- July 2023
- Special Alert June 2023 - Medicare Echo Scans and Nuclear Medicine
- June 2023
- May 2023
- COVID-19 Public Health Emergency Ending: Medical & Coding Policy Updates
- April 2023
- March 2023
- Special Alert February 2023 - Medicaid Review Guidelines for Early Periodic Screening Diagnostic and Treatment
- February 2023
- Special Alert January 2023 - Provider Satisfaction Survey
- January 2023
- Special Alert December 2022 - eviCore Medical Necessity Review Training
- Special Alert December 2022 (Update From October 2022 Call Out) - eviCore ASO Expansion
- Special Alert December 2022 - Covid 19 testing
- December 2022
- Special Alert December 2022 - Updates to AIM Clinical Appropriateness Guidelines
- November 2022
- Special Alert October 2022 - Covid 19 Testing
- October 2022
- September 2022
- August 2022
- July 2022
- eviCore Physical Therapy (PT) & Occupation Therapy (OT) Guidelines
- June 2022
- May 2022
- Special Alert April 2022 - InterQual 2022 Criteria Release
- April 2022
- Special Alert April 2022 - Inpatient Readmission Reimbursement Policy
- March 2022
- February 2022
- January 2022
- December 2021
- November 2021
- Special Alert June 2021 - Gender Affirming Surgical Interventions
- October 2021
- September 2021
- August 2021
- July 2021
- June 2021
- May 2021
- April 2021
- March 2021
- February 2021
- January 2021
- December 2020
- November 2020
- October 2020
- September 2020
- August 2020
- July 2020
- June 2020
- May 2020
- April 2020
- March 2020
- February 2020
- January 2020
- December 2019
- November 2019
- October 2019
- September 2019
- August 2019
- July 2019
- June 2019
- May 2019
- April 2019
- March 2019
- February 2019
- January 2019
- December 2018
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Company Medical Policies
**SPECIAL NOTICE**
Medical Policy Committee: External Provider Review
PHP/PHA Medical Policy Committee is looking to expand our group of external providers who serve as clinical subject matter experts (SMEs) through the policy development and annual review processes. We are seeking provider participation across various clinical specialties who will review and provide feedback on our medical policies. The medical policy specialties include (but are not limited to) pain management, behavioral health, endocrinology, genetics, orthopedics, neurology, urology, cardiology, oncology and general surgery. A complete list of medical policies is below.
COMPANY MEDICAL POLICIES
Specialty/Category
Allergy/Immunology
Audiology
Bariatric
Behavioral Health/ Psychiatrics
- Applied Behavior Analysis
- Biofeedback and Neurofeedback
- Extended Outpatient Psychotherapy
- Psychological and Neuropsychological Testing
- Residential Mental Health Treatment Facilities
- Transcranial Magnetic Stimulation
- Ultra-rapid Detoxification
- Wilderness Therapy
Cardiology
- Cardiac: Disease Risk Screening
- Cardiac: External Ambulatory Electrocardiography
- Cardiac: Implantable Loop Recorder
- Cardiac: Left Atrial Appendage Devices
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR)
Complementary and Alternative Medicine
Definitions and Manuals
Dental/Oral Surgery
Durable Medical Equipment
- Compression: Bandages, Stockings, and Wraps
- Compression: Outpatient Pneumatic Devices
- Continuous Passive Motion Device in the Home Setting
- Diabetes: Blood Glucose Monitors and Supplies
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- Home Oxygen Equipment and Supplies
- Mechanical Stretching Devices for Joints of the Extremities
- Seat Lift Mechanism
- Speech Generating Devices
- Standing Systems
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies
- Walkers
- Wheelchairs and Power Vehicles
Emergency Services
Endocrinology
EENT
Gastroenterology
- Colorectal Cancer Screening
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatments
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Peroral Endoscopic Myotomy (POEM)
- Wireless Capsule Endoscopy
- Wireless Capsule for Gastrointestinal Motility Monitoring
General Surgery
- Athletic Pubalgia/Sports Hernia Surgery
- Fecal Incontinence: Treatments
- Gender Affirming Surgical Interventions
Genetics
- Genetic and Molecular Testing
- Genetic Counseling
- Genetic Testing: CADASIL Disease
- Genetic Testing: Cytochrome P450 and VKORC1 Polymorphisms
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer
- Genetic Testing: Gene Expression Profile Testing for Melanoma
- Genetic Testing: Hereditary Breast and Ovarian Cancer
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer
- Genetic Testing: Inherited Thrombophilias
- Genetic Testing: MTHFR
- Genetic Testing: Myeloproliferative Diseases
- Genetic Testing: Non-Covered Genetic Panel Tests
- Genetic Testing: Reproductive Planning and Prenatal Testing
- Genetic Testing: Thyroid Nodules
- Genetic Testing: Whole Exome, Whole Genome, and Proteogenomic Testing
Infectious Disease
Investigational Technologies
Lab Tests
- Blood Counts
- Direct-to-Consumer Testing
- Drug Testing for Therapeutic or Substance Use Monitoring
- Exhaled Breath Tests
- Fecal Analysis of Gastrointestinal Microbiome
- Glycated Hemoglobin and Protein Diagnostic Testing
- Helicobacter Pylori Serological Testing
- Hepatitis Panel and Acute Hepatitis Panel Testing
- Inflammatory Bowel Disease (IBD): Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease: Measurement of Antibodies to Immunosuppressive Therapies
- Organic Acid Testing
- Lipid Testing
- Partial Thromboplastin Time (PTT)
- Salivary Hormone Testing
- Serum Iron Studies
- Thyroid Testing
- Vectra DA Test for Rheumatoid Arthritis
- Vitamin D Assay Testing
Nephrology
Neurology/Neurosurgery
- Blood Brain Barrier Disruption and Bypass
- Cochlear Implants and Auditory Brainstem Implants
- Deep Brain and Responsive Cortical Stimulation
- Magnetic Resonance Guided Focused Ultrasound
- Myoelectric Upper Limb Prosthesis
- Nerve Conduction Studies
- Surface Electromyography (sEMG) Testing
- Vagus Nerve Stimulation
Obstetrics and Gynecology
- Hysterectomy for Benign Conditions
- Pelvic Congestion Syndrome Treatment
- Planned Out of Hospital Birth
- Premature Rupture of Membranes (PROM) Testing
Oncology/Hematology
- Breast Cancer: Microwave Thermotherapy
- Chemoresistance and Chemosensitivity Assays
- Circulating Tumor Cell and DNA Assays For Cancer Management
- Liver Tumor Treatment
- NanoKnife System Irreversible Electroporation (IRE)
- Next Generation Sequencing for Minimal Residual Disease Detection
- Next Generation Sequencing for Cancer
- Non-Small Cell Lung Cancer: Tumor Testing for Targeted Therapy
- Ovarian Cancer: Multimarker Serum Testing
- Prostate: High Intensity Focused Ultrasound
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Protein Biomarkers and Genetic Testing
- Prostate Specific Antigen
- Proton Beam Radiation Therapy
- Radiofrequency Ablation for Tumors Outside the Liver
- Stem Cell Transplantation
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
- Tumor Treatment Fields Therapy for Glioblastoma
Opthalmology
Orthopedics
- Ankle-Foot/Knee-Ankle-Foot Orthoses
- Computer Assisted Navigation for Musculoskeletal Procedures
- Electrothermal Capsular Shrinkage
- Hip: Total Joint Arthroplasty
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Genicular Nerve Blocks and Nerve Ablation for Knee Pain
- Knee: Meniscal Allograft Transplantation and Other Meniscal Implants
- Lower Limb Prosthesis
- Orthotic Foot Devices and Therapeutic Shoes
- Osteochondral Allografts and Autografts for Cartilaginous Defects
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions
- Radiofrequency Ablation or Cryoablation for Plantar Fasciitis
- Surgical Site of Service
- Stem Cell Therapy for Orthopedic Applications
- Viscosupplementation
Pain Management
- Back: Epidural Steroid Injections
- Botulinum Toxin
- Cold Therapy and Cooling Devices in the Home Setting
- Electrical Stimulation: Non-Covered Therapies
- Functional Electrical Stimulation
- Ganglion Impar Blocks
- Low-Level and High-Power Laser Therapy
- Prolotherapy
Physical Medicine
Plastic Surgery
- Breast Surgery: Reduction Mammoplasty, Reconstructive Surgery and Implant Management
- Cosmetic and Reconstructive Procedures
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- Hemangioma and Vascular Malformation Treatment
- Liposuction for Lipedema
- Rhinoplasty and Other Nasal Surgeries
- Surgical Treatments for Lymphedema
- Surgical Treatment for Skin Redundancy
Podiatry
Pulmonology
Research
Sleep Physicians
- Sleep Disorder Testing
- Sleep Disorder Treatment: Oral and Sleep Position Appliances
- Sleep Disorder Treatment: Positive Airway Pressure
- Sleep Disorder Treatment: Surgical
Solid Organ Transplants
Spine Surgery (Neurosurgery/Orthopedic Surgery)
- Ablative Procedures to Treat Back and Neck Pain
- Back: Artificial Intervertebral Discs
- Back: Discography
- Back: Fusion and Decompression Procedures
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation
- Back: Intradiscal Procedures for Low Back Pain
- Back: Percutaneous Vertebroplasty and Sacroplasty
- Back: Sacroiliac Joint Fusion or Stabilization
- Back: Stabilization Devices and Interspinous Spacers
- Bone Growth Stimulators
- Intraoperative Monitoring
Urology
Vascular Surgery
Wound Care
Alphabetical
- Ablative Procedures to Treat Back and Neck Pain
- Advanced Diabetes Management Technology
- Allergy Testing
- Ambulance Transport
- Ankle-Foot/Knee-Ankle-Foot Orthoses
- Apheresis (Therapeutic Pheresis)
- Applied Behavior Analysis
- Athletic Pubalgia/Sports Hernia Surgery
- Back: Artificial Intervertebral Discs
- Back: Discography
- Back: Epidural Steroid Injections
- Back: Fusion and Decompression Procedures
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation
- Back: Intradiscal Procedures for Low Back Pain
- Back: Percutaneous Vertebroplasty and Sacroplasty
- Back: Sacroiliac Joint Fusion or Stabilization
- Back: Stabilization Devices and Interspinous Spacers
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Bariatric Surgery
- Biofeedback and Neurofeedback
- Blood Brain Barrier Disruption and Bypass
- Blood Counts
- Bone Growth Stimulators
- Botulinum Toxin
- Breast Cancer: Microwave Thermotherapy
- Breast Surgery: Reduction Mammoplasty, Reconstructive Surgery and Implant Management
- Bronchial Thermoplasty
- Cardiac: Disease Risk Screening
- Cardiac: External Ambulatory Electrocardiography
- Cardiac: Implantable Loop Recorder
- Cardiac: Left Atrial Appendage Devices
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR)
- Chemoresistance and Chemosensitivity Assays
- Chiropractic Care
- Circulating Tumor Cell and DNA Assays For Cancer Management
- Clinical Trials
- Cochlear Implants and Auditory Brainstem Implants
- Cold Therapy and Cooling Devices in the Home Setting
- Colorectal Cancer Screening
- Complementary and Alternative Medicine
- Compression: Bandages, Stockings, and Wraps
- Compression: Outpatient Pneumatic Devices
- Computer Assisted Navigation for Musculoskeletal Procedures
- Continuous Passive Motion Device in the Home Setting
- Cosmetic and Reconstructive Procedures
- Covid 19 Testing
- Deep Brain and Responsive Cortical Stimulation
- Definition of Investigational
- Definition of Medical Necessity
- Dental Anesthesia Services
- Dental Services: Administrative Guideline
- Diabetes: Blood Glucose Monitors and Supplies
- Direct-to-Consumer Testing
- Drug Testing for Therapeutic or Substance Use Monitoring
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- Electrical Stimulation: Non-Covered Therapies
- Electrothermal Capsular Shrinkage
- Exhaled Breath Tests
- Extended Outpatient Psychotherapy
- Eye: Automated Evacuation of Meibomian Gland
- Eye: Blepharoplasty, Blepharoptosis, and Brow Lift
- Eye: Corneal Collagen Cross-Linking
- Fecal Analysis of Gastrointestinal Microbiome
- Fecal Incontinence: Treatments
- Foot Care Guidelines
- Functional Electrical Stimulation
- Ganglion Impar Blocks
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatment
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Gender Affirming Surgical Interventions
- Genetic and Molecular Testing
- Genetic Counseling
- Genetic Testing: CADASIL Disease
- Genetic Testing: Cytochrome P450 and VKORC1 Polymorphisms
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer
- Genetic Testing: Gene Expression Profile Testing for Melanoma
- Genetic Testing: Hereditary Breast and Ovarian Cancer
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer
- Genetic Testing: Inherited Thrombophilias
- Genetic Testing: MTHFR
- Genetic Testing: Myeloproliferative Diseases
- Genetic Testing: Non-Covered Genetic Panel Tests
- Genetic Testing: Reproductive Planning and Prenatal Testing
- Genetic Testing: Thyroid Nodules
- Genetic Testing: Whole Exome, Whole Genome, and Proteogenomic Testing
- Glycated Hemoglobin and Protein Diagnostic Testing
- Hearing Aids
- Helicobacter Pylori Serological Testing
- Hemangioma and Vascular Malformation Treatment
- Hepatitis Panel and Acute Hepatitis Panel Testing
- Hip: Total Joint Arthroplasty
- Home Oxygen Equipment and Supplies
- Hyperbaric Oxygen Therapy
- Hysterectomy for Benign Conditions
- Inflammatory Bowel Disease (IBD): Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease: Measurement of Antibodies to Immunosuppressive Therapies
- Intraoperative Monitoring
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Genicular Nerve Blocks and Nerve Ablation for Knee Pain
- Knee: Meniscal Allograft Transplantation
- Lipid Testing
- Liposuction for Lipedema
- Liver Tumor Treatment
- Low-Level and High-Power Laser Therapy
- Lower Limb Prosthesis
- Magnetic Resonance Guided Focused Ultrasound
- Mechanical Stretching Devices for Joints of the Extremities
- Myoelectric Upper Limb Prosthesis
- NanoKnife System Irreversible Electroporation (IRE)
- Negative Pressure Wound Therapy (NPWT)
- Nerve Conduction Studies
- New and Emerging Technologies and Other Non-Covered Services
- Next Generation Sequencing for Minimal Residual Disease Detection
- Next Generation Sequencing for Cancer
- Non-Small Cell Lung Cancer: Tumor Testing for Targeted Therapy
- Organ Transplantation
- Organic Acid Testing
- Orthognathic Surgery
- Orthotic Foot Devices and Therapeutic Shoes
- Osteochondral Allografts and Autografts for Cartilaginous Defects
- Outpatient Physical Therapy
- Ovarian Cancer: Multimarker Serum Testing
- Partial Thromboplastin Time (PTT)
- Pelvic Congestion Syndrome Treatment
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Peroral Endoscopic Myotomy (POEM)
- Planned Out of Hospital Birth
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions
- Premature Rupture of Membranes (PROM) Testing
- Prolotherapy
- Prostate: Benign Prostatic Hyperplasia Treatments
- Prostate: High Intensity Focused Ultrasound
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Protein Biomarkers and Genetic Testing
- Prostate Specific Antigen
- Proton Beam Radiation Therapy
- Psychological and Neuropsychological Testing
- Radiofrequency Ablation for Tumors Outside the Liver
- Radiofrequency Ablation or Cryoablation for Plantar Fasciitis
- Residential Mental Health Treatment Facilities
- Respiratory Viral Panels
- Rhinoplasty and Other Nasal Surgeries
- Salivary Hormone Testing
- Seat Lift Mechanism
- Serum Iron Studies
- Skin and Tissue Substitutes
- Sleep Disorder Testing
- Sleep Disorder Treatment: Oral and Sleep Position Appliances
- Sleep Disorder Treatment: Positive Airway Pressure
- Sleep Disorder Treatment: Surgical
- Speech Generating Devices
- Standing Systems
- Stem Cell Therapy for Orthopedic Applications
- Stem Cell Transplantation
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
- Surface Electromyography (sEMG) Testing
- Surgical Site of Service
- Surgical Treatment for Skin Redundancy
- Surgical Treatments for Lymphedema
- Thyroid Testing
- Transcranial Magnetic Stimulation
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies
- Tumor Treatment Fields Therapy for Glioblastoma
- Ultra-rapid Detoxification
- Urinary Incontinence Treatments
- Vagus Nerve Stimulation
- Varicose Veins
- Vectra DA Test for Rheumatoid Arthritis
- Vestibular Function Testing
- Viscosupplementation
- Vitamin D Assay Testing
- Walkers
- Wheelchairs and Power Vehicles
- Wilderness Therapy
- Wireless Capsule Endoscopy
- Wireless Capsule for Gastrointestinal Motility Monitoring
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Medicare Medical Policies
MEDICARE MEDICAL POLICIES
Specialty/Category
Allergy/Immunology
Audiology
Bariatric
Behavioral Health/ Psychiatrics
- Biofeedback and Neurofeedback
- Extended Outpatient Psychotherapy
- Transcranial Magnetic Stimulation
- Ultra-rapid Detoxification
Cardiology
- Cardiac: Disease Risk Screening
- Cardiac: External Ambulatory Electrocardiography
- Cardiac: Implantable Loop Recorders
- Cardiac: Left Atrial Appendage Devices
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR)
Complementary and Alternative Medicine
Definitions and Manuals
Dental/Oral Surgery
Durable Medical Equipment
- Compression: Bandages, Stockings, and Wraps
- Compression: Outpatient Pneumatic Devices
- Continuous Passive Motion Devices in the Home Setting
- Diabetes: Blood Glucose Monitors and Supplies
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- Home Oxygen Equipment and Supplies
- Mechanical Stretching Devices for Joints of the Extremities
- Seat Lift Chair Mechanism
- Speech Generating Devices
- Standing Systems
- Walkers
- Wheelchairs and Power Vehicles
Emergency Services
Endocrinology
EENT
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Eye: Automated Evacuation of the Meibomian Gland
Gastroenterology
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatments
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Peroral Endoscopic Myotomy (POEM)
- Wireless Capsule Endoscopy
- Wireless Capsule for Gastrointestinal Motility Monitoring
General Surgery
- Athletic Pubalgia/Sports Hernia Surgery
- Fecal Incontinence: Treatments
- Gender Affirming Surgical Interventions
Genetics
- Genetic and Molecular Testing
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer
- Genetic Testing: Gene Expression Profile Testing for Melanoma
- Genetic Testing: Myeloproliferative Diseases
- Genetic Testing: Thyroid Nodules
Infectious Disease
New and Emerging Technologies
Lab Tests
- Blood Counts
- Drug Testing for Therapeutic or Substance Use Monitoring
- Exhaled Breath Tests
- Fecal Analysis of Gastrointestinal Microbiome
- Glycated Hemoglobin and Protein Diagnostic Testing
- Helicobacter Pylori Serological Testing
- Hepatitis Panel and Acute Hepatitis Panel Testing
- Inflammatory Bowel Disease: Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease: Measurement of Antibodies to Immunosuppressive Therapies
- Organic Acid Testing
- Lipid Testing
- Partial Thromboplastin Time (PTT)
- Salivary Hormone Testing
- Serum Iron Studies
- Thyroid Testing
- Vitamin D Assay Testing
Nephrology
Neurology/Neurosurgery
- Blood Brain Barrier Disruption and Bypass
- Cochlear Implants and Auditory Brainstem Implants
- Magnetic Resonance-Guided Focused Ultrasound Surgery
- Myoelectric Upper Limb Prosthesis
- Nerve Conduction Studies
- Surface Electromyography (sEMG) Testing
Obstetrics and Gynecology
Oncology/Hematology
- Breast Cancer: Microwave Thermotherapy
- Radiofrequency Ablation for Tumors Outside the Liver
- Chemosensitivity and Chemoresistance Assays (CSRAs)
- Circulating Tumor Cell and DNA Assays For Cancer Management
- Liver Tumor Treatment
- NanoKnife System Irreversible Electroporation (IRE)
- Next Generation Sequencing for Minimal Residual Disease Detection
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Protein Biomarkers and Genetic Testing
- Prostate Specific Antigen
- Proton Beam Radiation Therapy
- Stem Cell Transplantation
- Tumor Treatment Fields Therapy for Glioblastoma
Orthopedics
- Ankle-Foot/Knee-Ankle-Foot Orthoses
- Electrothermal Capsular Shrinkage
- Hip Total Joint Arthroplasty
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Genicular Nerve Blocks and Nerve Ablation for Knee Pain
- Knee: Meniscal Allograft Transplantation and Other Meniscal Implants
- Lower Limb Prosthesis
- Orthotic Foot Devices and Therapeutic Shoes
- Osteochondral Allografts and Autografts for Cartilaginous Defects
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions
- Radiofrequency Ablation or Cryoablation for Plantar Fasciitis
- Surgical Site of Service
- Stem Cell Therapy for Orthopedic Applications
- Viscosupplementation
Pain Management
- Back: Epidural Steroid Injections
- Botulinum Toxin
- Cold Therapy and Cooling Devices in the Home Setting
- Electrical Stimulation and Electromagnetic Therapies
- Ganglion Impar Blocks
- Low-Level and High-Power Laser Therapy
- Prolotherapy
Physical Medicine
Plastic Surgery
- Breast Surgery: Reduction Mammoplasty, Reconstructive Surgery and Implant Management
- Cosmetic and Reconstructive Procedures
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- Hemangioma and Vascular Malformation Treatment
- Liposuction for Lipedema
- Rhinoplasty and Other Nasal Surgeries
- Surgical Treatments for Lymphedema
- Surgical Treatment for Skin Redundancy
Podiatry
Pulmonology
Research
Sleep Physicians
- Sleep Disorder Testing
- Sleep Disorder Treatment: Oral and Sleep Position Appliances
- Sleep Disorder Treatment: Positive Airway Pressure
- Sleep Disorder Treatment: Surgical
Solid Organ Transplants
Spine Surgery (Neurosurgery/Orthopedic Surgery)
- Ablative Procedures to Treat Back and Neck Pain
- Back: Artificial Intervertebral Discs
- Back: Discography
- Back: Fusion and Decompression Procedures
- Back: Intradiscal Procedures for Low Back Pain
- Back: Percutaneous Vertebroplasty and Sacroplasty
- Back: Sacroiliac Joint Fusion or Stabilization
- Back: Stabilization Devices and Interspinous Spacers
- Bone Growth Stimulators
- Intraoperative Monitoring
Urology
Vascular Surgery
Wound Care
Alphabetical
- Ablative Procedures to Treat Back and Neck Pain
- Advanced Diabetes Management Technology
- Allergy Testing
- Ambulance Transport
- Ankle-Foot/Knee-Ankle-Foot Orthoses
- Apheresis (Therapeutic Pheresis)
- Applied Behavior Analysis
- Athletic Pubalgia/Sports Hernia Surgery
- Back: Artificial Intervertebral Discs
- Back: Discography
- Back: Epidural Steroid Injections
- Back: Fusion and Decompression Procedures
- Back: Intradiscal Procedures for Low Back Pain
- Back: Percutaneous Vertebroplasty and Sacroplasty
- Back: Sacroiliac Joint Fusion or Stabilization
- Back: Stabilization Devices and Interspinous Spacers
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Bariatric Surgery
- Biofeedback and Neurofeedback
- Blood Brain Barrier Disruption and Bypass
- Blood Counts
- Bone Growth Stimulators
- Botulinum Toxin
- Breast Cancer: Microwave Thermotherapy
- Breast Surgery: Reduction Mammoplasty, Reconstructive Surgery and Implant Management
- Bronchial Thermoplasty
- Cardiac: Disease Risk Screening
- Cardiac: External Ambulatory Electrocardiography
- Cardiac: Implantable Loop Recorders
- Cardiac: Left Atrial Appendage Devices
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR)
- Chemosensitivity and Chemoresistance Assays (CSRAs)
- Chiropractic Care
- Circulating Tumor Cell and DNA Assays For Cancer Management
- Clinical Trials, Studies and Registries
- Cochlear Implants and Auditory Brainstem Implants
- Cold Therapy and Cooling Devices in the Home Setting
- Complementary and Alternative Medicine
- Compression: Bandages, Stockings, and Wraps
- Compression: Outpatient Pneumatic Devices
- Continuous Passive Motion Devices in the Home Setting
- Cosmetic and Reconstructive Procedures
- Covid 19 Testing
- Definition of Medically Reasonable and Necessary
- Dental Anesthesia Services
- Dental Services: Administrative Guideline
- Diabetes: Blood Glucose Monitors and Supplies
- Drug Testing for Therapeutic or Substance Use Monitoring
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- Electrical Stimulation and Electromagnetic Therapies
- Electrothermal Capsular Shrinkage
- Exhaled Breath Tests
- Extended Outpatient Psychotherapy
- Eye: Automated Evacuation of the Meibomian Gland
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- Fecal Analysis of Gastrointestinal Microbiome
- Fecal Incontinence: Treatments
- Foot Care Guidelines
- Ganglion Impar Blocks
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatments
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Gender Affirming Surgical Interventions
- Genetic and Molecular Testing
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer
- Genetic Testing: Gene Expression Profile Testing for Melanoma
- Genetic Testing: Myeloproliferative Diseases
- Genetic Testing: Thyroid Nodules
- Glycated Hemoglobin and Protein Diagnostic Testing
- Helicobacter Pylori Serological Testing
- Hemangioma and Vascular Malformation Treatment
- Hepatitis Panel and Acute Hepatitis Panel Testing
- Hip Total Joint Arthroplasty (Medicare Only)
- Home Oxygen Equipment and Supplies
- Hyperbaric Oxygen Therapy (Medicare Only)
- Inflammatory Bowel Disease: Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease: Measurement of Antibodies to Immunosuppressive Therapies
- Intraoperative Monitoring
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Genicular Nerve Blocks and Nerve Ablation for Knee Pain
- Knee: Meniscal Allograft Transplantation and Other Meniscal Implants
- Lipid Testing
- Liposuction for Lipedema
- Liver Tumor Treatment
- Low-Level and High-Power Laser Therapy
- Lower Limb Prosthesis
- Magnetic Resonance-Guided Focused Ultrasound Surgery
- Mechanical Stretching Devices for Joints of the Extremities
- Myoelectric Upper Limb Prosthesis
- NanoKnife System Irreversible Electroporation (IRE)
- Negative Pressure Wound Therapy (NPWT)
- Nerve Conduction Studies
- New and Emerging Technologies and Other Non-Covered Services
- Next Generation Sequencing for Minimal Residual Disease Detection
- Organ Transplantation
- Organic Acid Testing
- Orthognathic Surgery
- Orthotic Foot Devices and Therapeutic Shoes
- Osteochondral Allografts and Autografts for Cartilaginous Defects
- Outpatient Physical Therapy
- Partial Thromboplastin Time (PTT)
- Pelvic Congestion Syndrome Treatment
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Peroral Endoscopic Myotomy (POEM)
- PHA Medicare Medical Policy Manual
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions
- Premature Rupture of Membranes (PROM) Testing
- Prolotherapy
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Protein Biomarkers and Genetic Testing
- Prostate Specific Antigen
- Proton Beam Radiation Therapy
- Radiofrequency Ablation for Tumors Outside the Liver
- Radiofrequency Ablation or Cryoablation for Plantar Fasciitis
- Rehabilitation: Acute Inpatient
- Residential Mental Health Treatment Facilities
- Respiratory Viral Panels
- Rhinoplasty and Other Nasal Surgeries
- Salivary Hormone Testing
- Seat Lift Chair Mechanism
- Serum Iron Studies
- Skin and Tissue Substitutes
- Sleep Disorder Testing
- Sleep Disorder Treatment: Oral and Sleep Position Appliances
- Sleep Disorder Treatment: Positive Airway Pressure
- Sleep Disorder Treatment: Surgical
- Speech Generating Devices
- Standing Systems
- Stem Cell Therapy for Orthopedic Applications
- Stem Cell Transplantation
- Surface Electromyography (sEMG) Testing
- Surgical Site of Service
- Surgical Treatment for Skin Redundancy
- Surgical Treatments for Lymphedema
- Thyroid Testing
- Transcranial Magnetic Stimulation
- Tumor Treatment Fields Therapy for Glioblastoma
- Ultra-rapid Detoxification
- Urinary Incontinence Treatments
- Varicose Veins
- Vestibular Function Testing
- Viscosupplementation
- Vitamin D Assay Testing
- Walkers
- Wheelchairs and Power Vehicles
- Wireless Capsule Endoscopy
- Wireless Capsule for Gastrointestinal Motility Monitoring
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Provider Satisfaction Survey
Provider Satisfaction Survey
Providence cares about the experience of our providers. Please click the link below to provide feedback on your experience as a provider working with Providence Health Plan. We look forward to hearing from you.
Thank you!
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Credentialing Services
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Reimbursement Policies
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Pharmacy Policies
*NEW* NDC Required for Medical Claims Reimbursement effective 11/1/2023
Providence Health Plan (PHP) is now requiring providers to submit National Drug Codes (NDCs) on provider drug claims and hospital outpatient facility claims that are reported for reimbursement. This new PHP requirement will begin November 1st, 2023.
- Brand Drug Definition, Benefit Administration and Payment Policy revised and approved by ORPTC on August 4, 2023.
National Drug Code (NDC) numbers are the industry standard identifier for drugs and provide full transparency to the medication administered. The NDC number identifies the manufacturer, drug name, dosage, strength, package size and quantity.
For purposes of this policy, a valid NDC number, NDC unit of measure and NDC units dispensed for the drug administered will be required for reimbursement of professional drug claims on a1500 Health Insurance Claim Form (a/k/a CMS-1500), the 837-professional transaction, a UB-04 Claim Form or the 837i facility transaction.
Drug Prior Authorization
Below you will find lists of drugs with their associated medical necessity criteria for coverage. Please select the list of drugs based on the medical plan of your patient (e.g., Commercial, Medicaid, Medicare). You may use the drug prior authorization request form below to request authorization for a drug.
Please note that the presence of drugs on these lists does not indicate that the particular drug will be covered under your patient’s medical or prescription drug benefit. You can verify drug coverage by accessing your patient’s formulary on the pharmacy resources page.
Formulary exceptions: There may be times that you prescribe a drug that is not on your patient’s formulary. You may want to consider prescribing a formulary alternative for your patient; however, you may also request a formulary exception for the drug you wish to prescribe by using the drug prior authorization form below.
Drug Prior Authorization Request Form
Commercial Plans
Medicare Plans
- 2023 Medicare Part D Pharmacy Policy Criteria
- 2023 Step Therapy Drug List for Medicare Part B
- 2023 Prior Authorization Criteria for Medicare Part B Drugs
Medicaid Plans
Biosimilar Preferred Product Program
Providence Health Plan (PHP) implemented a biosimilar preferred product formulary strategy for medical benefit drugs effective July 1, 2021. The October 2021 Oregon Regional Pharmacy and Therapeutics Committee (ORPTC) approved expansion of the biosimilar preferred product formulary to include infliximab products. This change is effective January 1, 2022.
- PHP Provider Information and Biosimilar Preferred Product Drug List
- PHP Biosimilar Preferred Product Drug List
Refer to the policies below for clinical criteria by line of business:
Commercial and Medicaid:
- Injectable Anti-Cancer Medications Policy - Commercial and Medicaid
- Rituximab Policy - Commercial and Medicaid
- Therapeutic Immunomodulators (TIMs) Policy - Medicaid
- Medically Infused Therapeutic Immunomodulators (TIMs) Policy - Commercial
Medicare Part B:
- Medically Infused Therapeutic Immunomodulators (TIMs) Policy - Medicare Part B
- Injectable Anti-Cancer Medications Policy - Medicare Part B
- Rituximab Policy - Medicare Part B
Infusion Therapy Site of Care (SOC)
Providence Health Plan (PHP) requires site of care prior authorization for the medications listed below when given in an unapproved hospital setting. A separate prior authorization may be required for the drug. Refer to the Commercial Infusion Therapy SOC Policy link below.
- Infusion Therapy SOC Policy - Effective 8/1/2022
- Infusion Therapy SOC Policy - Effective 1/1/2023
- Site of Care Prior Authorization Request Form
Infusion Therapy Site of Care Facility Contracting:
- Approved Site of Care Facility List
- 2023 Outpatient Infusion Services SOC Contract list of Drug Codes
Specialty Drugs Shipped from Pharmacies to Providers and Facilities ("White Bagging")
- Specialty Drugs Shipped from Pharmacies to Providers and Facilities - Operational Policy
Self-Administered Drug Exclusion Policy
Self-Administered Drugs definition - Medications which have been identified as being medically appropriate for administration by a patient or caregiver, safely and effectively, without medical supervision.
Certain medications considered to be usually self-administered by the patient or their caregiver are excluded from coverage under the medical benefit without prior-authorization.
- Self-Administered Drug Exclusion Policy - Commercial and Medicaid
- Medicare Part B – Refer to Noridian Healthcare Solutions’ Self-Administered Drugs (SADs) Policy: https://med.noridianmedicare.com/web/jfb/policies/sads
- Self-Administered Drug Exclusion Drug List - Applies to All Lines of Business
Opioid Resources and Guidelines
- PHP has created a list of links designed to empower providers to make evidence based decisions when starting opioid therapy as well provide support when taper is indicated.
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Outpatient Rehabilitation
eviCore ASO Expansion
Please be aware that several Self-Funded Administrative Only (ASO) group plans will be adding the use of eviCore medical necessity reviews for outpatient rehabilitation, group and renewal dates provided below. Providers will need to request medical necessity review through eviCore healthcare for dates of service starting on plan renewal dates, as outlined below.
* Please note that Providence will continue to require a request to eviCore on all Commercial and Individual members.
For additional information, including eviCore’s clinical guidelines and a complete list of services requiring medical necessity review, please visit: https://www.eviCore.com/healthplan/PHP or call the eviCore Client Provider Operations department at (800) 646-0418 (Option #4).
The following ASO plans become effective with the process outlined above on the following dates:
Effective 1/1/2023:
- Providence St. Joseph Health Groups (including Providence Health & Services, Swedish Health Services, Kadlec, Pacific Medical Centers, St. Joseph Health, and Covenant Health)
- Clackamas County
- COLLEGENET Inc
- Covenant Health
- Umpqua Health LLC
- Riverpoint Medical
- Oregon Episcopal School
- SAIF Corporation
Effective 2/1/2023:
- Combined Transport, Inc.
Effective 4/1/2023:
- School District Trust
Effective 6/1/2023:
- Orthopedic and Fracture Clinic PC
Effective 8/1/2023:
- Jet Industries
Effective 9/1/2023:
- Nosler
- Hydra Power
Effective 10/1/2023:
- Valley View Health
Effective 1/1/2024:
- PEBB
The following ASO plans do not require eviCore:
- Intel
- Marathon Coach
Outpatient Rehabilitation Resources
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No Surprises Act
Reimbursement to providers and facilities for services subject to the No Surprises Act are paid according to the qualifying payment amount (QPA) as defined by the No Surprises Act. The methodology for calculating the QPA was determined by the Plan to be consistent with the requirements of the No Surprises Act. If the out-of-network provider or facility wishes to initiate a 30 business day negotiation period, they may contact ClearHealth via https://clearhs.com, claimsinquiry@clearhs.com, or by calling (866) 722-3773. Independent Dispute Resolution may be initiated within 4 days after the end of the 30 day negotiation period.
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Contact Us
The PHP Medical Policy Team only deals with evidence-based reviews around published medical policies. All inquiries concerning PHP medical policies or new medical devices and technologies may be sent by filling out our online form
Do not submit the Medical Policy Inquiry Feedback form for questions regarding pricing, benefits, claims, EOB statements, or contract issues. Medical policy staff cannot answer or forward these issues. Please contact Customer Service or Provider Relations for assistance with the above.
If you are a member please do not use this form. Please call customer service.
Medical Policy Inquiry Form
Provider Relations can be contacted here: https://healthplans.providence.org/providers/provider-support/provider-relations-representatives/
Customer Service can be reached at: 503-574-7500 or 800-878-4445 (TTY: 711); or at https://healthplans.providence.org/about-us/contact-us/
For questions related to pharmaceuticals please contact our PHP Pharmacy Policy Team at PHPRX@providence.org.