Online Formulary

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InterCommunity Health Network CCO

For questions please call:

Members: 866-203-3435 or 541-768-7863, TTY 1-800-735-2900

Providers: 1-888-435-2396

Vaccines: For members up to age 18 years old vaccines must be administered in a providers office.

Note: This plan has limits on Opioid Medications. See page footer for details.

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Opioid anti-tussive limits:

Liquids: Maximum of 240ML per fill.
Tablets/Capsules: Maximum 7-day supply per fill.

Short-acting Opioid (SAO) Limits:

New to therapy: Maximum of 49 MED and Maximum 7-day supply per fill.
Experience with therapy: Maximum of 90 MED.

Long-acting Opioid (LOA) Limits: PA required and Maximum of 90 MED.

You can get this document in another language, format, large print or ask for an interpreter at no cost to you. Please call us at 866-203-3435 (TTY 800-735-2900) to request a copy of this document or an interpreter.

Puede obtener este documento en otro idioma, otro formato o en letra grande o pedir un intérprete sin costo alguno para usted. Llámenos al 866-203-3435 (TTY 800-735-2900) para pedir una copia de este documento o un intérprete.

Formulary Effective Date: 01/01/2026

Updated:

01/2026

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