Medical Policy, Pharmacy Policy, and Provider Information

Providence Health Plans, Providence Health Assurance, and Providence Health Plan Partners: 

Prior-authorization, Non-covered, and DME and Supplies Lists

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.

General Prior Authorization Requirements

Medical, Pharmacy, Billing, Payment, and Coding Policy Alerts

Medical Policy

Providence Health Plan (PHP), Providence Health Assurance (PHA), and Providence Health Plan Partners (PPP) Medical Policies serve as guidance for the administration of plan benefits. Medical policies do not constitute medical advice nor a guarantee of coverage. PHP, PHA, and PPP Medical Policies are reviewed annually and are based upon published, peer-reviewed scientific evidence and evidence-based clinical practice guidelines that are available as of the last policy update. PHP, PHA, and PPP reserve the right to determine the application of Medical Policies and make revisions to its Medical Policies at any time. Providers will be given 60-days’ notice of policy changes that are restrictive in nature.

The scope and availability of all plan benefits are determined in accordance with the applicable coverage agreement. Any conflict or variance between the terms of the coverage agreement and PHP, PHA, and PPP Medical Policy will be resolved in favor of the coverage agreement.

Pharmacy Policy

Outpatient Rehabilitation