What’s changing with acne?

by Cory Bradley, PharmD

Historically, nearly all acne cases have not been funded under Oregon Medicaid. Oregon Medicaid coverage is tied to the Prioritized List of Health Services. This list ranks conditions from top (most critical) to bottom (least critical). The number of conditions that are funded changes over time based on the available budget. 

Starting in 2020, the OHA has added a new guideline note which expands coverage for more acne cases to be above the funding line. Severe cystic acne with documented inflammatory nodules, cysts, and ongoing scarring as well as acne conglobata and acne fulminans with documented abscesses or communicating sinuses are now covered.

Accordingly, CareOregon is making some changes to its Medicaid formulary for 1/1/2020 to expand coverage options for acne. Some options will be available without PA. Some options require PA to ensure the diagnoses meet the guideline note. The last line option, isotretinoin, will have more rigorous clinical criteria. 

See the table below which outlines the formulary coverage for 2020.

image