Pharmacy Information for Providers

The Advanced Health Formulary is a list of medications that are covered for Advanced Health members. Some medications listed on the formulary require a prior authorization to ensure the least costly alternatives for treatment are utilized, and the condition being treated is funded for coverage by Oregon Health Plan.

Any medication may be requested for coverage, regardless of formulary status, through the prior authorization process.

Submission of a prior authorization request is not a guarantee of coverage, as certain requirements and criteria must be met in order for a prior authorization request to be approved.

Any prescription over $500 requires a prior authorization, even if the medication is on the Advanced Health Formulary.

Advanced Health is a mandatory generic plan, therefore, generic medications must be used when commercially available.

Mental Health medications are covered directly by the State Medical Assistance Program (MAP, previously known as the Division of Medical Assistance Programs or DMAP) as part of the mental health (or 7/11) carve-out.

Please contact Advanced Health Customer Service at (541) 269-7400 if you have any questions or need assistance.

For general formulary questions or any other questions, you can also email Advanced Health Pharmacy Department at ahpharmacy@advancedhealth.com. Please do NOT include member PHI.

Mail-Order Medications:

Please contact Postal Prescription Services (PPS) at 800-552-6694 to establish a new member profile. Advanced Health members are enrolled under “Doctors of the Oregon Coast” plan. New member profile and prescription transfer requests may be made by phone. PPS Customer New Prescription Request PPS Mail-Order Quick Reference Guide

Drug Formulary 

“To search the formulary, press Ctrl F and type in the drug name you are looking for.”

Formulary Updates

DRUG USE CRITERIA AND GUIDELINES

Fee For Service (FFS) Drug Use Criteria will be used for coverage determinations for which Advanced Health drug use criteria is not available.
Click the link below for more information.

https://www.orpdl.org/drugs/

Acute Pain

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Anaphylaxis

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Anemia

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Asthma

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Attention Deficit/Hyperactivity Disorders (ADHD)

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GUIDELINE NOTE 20, ATTENTION DEFICIT/HYPERACTIVITY DISORDERS IN CHILDREN

Line 121

Use of ICD-10-CM F90.9, Attention deficit/hyperactivity disorder, unspecified type, in children age 5 and under, is appropriate only when the following apply:

  • Child does not meet the full criteria for the full diagnosis because of their age.
  • For children age 3 and under, when the child exhibits functional impairment due to hyperactivity that is clearly in excess of the normal activity range for age (confirmed by the evaluating clinician’s observation, not only the parent/caregiver report), and when the child is very limited in his/her ability to have the sustained periods of calm, focused activity which would be expected for the child’s age.

For children age 5 and under diagnosed with disruptive behavior disorders, including those at risk for ADHD, first line therapy is evidence-based, structured “parent-behavior training. Second line therapy is pharmacotherapy.

For children age 6 and over who are diagnosed with ADHD, pharmacotherapy alone or pharmacotherapy with psychosocial/behavioral treatment are included on this line for first line therapy.

The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx

Atrial Fibrillation

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Autoimmune Diseases

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GUIDELINE NOTE 198, HIDRADENITIS SUPPURATIVA

Lines 418,​514

Hidradenitis suppurativa is included on Line 418 only for moderate to severe disease (e.g. Hurley Stage II or Hurley Stage III); otherwise this condition is included on Line 514.

Initial treatment with adalimumab is limited to adults whose disease has not responded to at least a 90-day trial of conventional therapy (e.g., oral antibiotics), unless such a trial is not tolerated or contraindicated. Treatment with adalimumab after 12 weeks is only included on Line 418 for patients with a clear evidence of response, defined as:

  1. a reduction of 25% or more in the total abscess and inflammatory nodule count, AND
  2. no increase in abscesses and draining fistulas.

GUIDELINE NOTE 21, SEVERE INFLAMMATORY SKIN DISEASE

Lines 426,​482,​504,​533,​542,​656

Inflammatory skin conditions included in this guideline are:

  1. Psoriasis
  2. Atopic dermatitis
  3. Lichen planus
  4. Darier disease
  5. Pityriasis rubra pilaris
  6. Discoid lupus
  7. Vitiligo

The conditions above are included on Line 426 if severe, defined as having functional impairment as indicated by Dermatology Life Quality Index (DLQI) ≥ 11 or Children’s Dermatology Life Quality Index (CDLQI) ≥ 13 (or severe score on other validated tool) AND one or more of the following:

  1. At least 10% of body surface area involved
  2. Hand, foot, face, or mucous membrane involvement.

Otherwise, these conditions above are included on Lines 482, 504, 533, 542 and 656.

For severe psoriasis, first line agents include topical agents, phototherapy and methotrexate. Second line agents include other systemic agents and oral retinoids and should be limited to those who fail, or have contraindications to, or do not have access to first line agents. Biologics are included on this line only for the indication of severe plaque psoriasis; after documented failure of first line agents and failure of (or contraindications to) a second line agent.

For severe atopic dermatitis/eczema, first-line agents include topical moderate- to high- potency corticosteroids and narrowband UVB.  Second line agents include topical calcineurin inhibitors (e.g. pimecrolimus, tacrolimus), topical phosphodiesterase (PDE)-4 inhibitors (e.g. crisaborole), and oral immunomodulatory therapy (e.g. cyclosporine, methotrexate, azathioprine, mycophenolate mofetil, or oral corticosteroids).  Use of the topical second line agents (e.g. calcineurin inhibitors and phosphodiesterase (PDE)-4 inhibitors) should be limited to those who fail or have contraindications to first line agents. Biologic agents are included on this line for atopic dermatitis only after failure of or contraindications to at least one agent from each of the following three classes: 1) moderate to high potency topical corticosteroids, 2) topical calcineurin inhibitors or topical phosphodiesterase (PDE)-4 inhibitors, and 3) oral immunomodulator therapy.

ICD-10-CM Q82.8 (Other specified congenital malformations of skin) is included on Line 426 only for Darier disease.

Binge Eating Disorder

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Cardiology

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Chronic Pain

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GUIDELINE NOTE 56, NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE

Lines 361,​402

Patients seeking care for back pain should be assessed for potentially serious conditions (“red flag” symptoms requiring immediate diagnostic testing), as defined in Diagnostic Guideline D4. Patients lacking red flag symptoms should be assessed using a validated assessment tool (e.g. STarT Back Assessment Tool) in order to determine their risk level for poor functional prognosis based on psychosocial indicators.

For patients who are determined to be low risk on the assessment tool, the following services are included on these lines:

  • Office evaluation and education,
  • Up to four total visits, consisting of the following treatments: OMT/CMT, acupuncture, and PT/OT. Massage, if available, may be provided as part of these four total visits.
  • First line medications: NSAIDs, acetaminophen, and/or muscle relaxers. Opioids may be considered as a second line treatment, subject to the limitations on coverage of opioids in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE.

For patients who are determined to be medium- or high risk on the validated assessment tool, as well as patients undergoing opioid tapers as in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE, the following treatments are included on these lines:

  • Office evaluation, consultation and education
  • Cognitive behavioral therapy. The necessity for cognitive behavioral therapy should be re-evaluated every 90 days and coverage will only be continued if there is documented evidence of decreasing depression or anxiety symptomatology, improved ability to work/function, increased self-efficacy, or other clinically significant, objective improvement.
  • Prescription and over-the-counter medications; opioid medications subject to the limitations on coverage of opioids in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE.
  • The following evidence-based therapies, when available, may be provided: yoga, massage when not billed under 97124 and limited to one session per week, Pilates, supervised exercise therapy, intensive interdisciplinary rehabilitation. HCPCS S9451 is only included on Line 402 for the provision of yoga or supervised exercise therapy.
  • A total of 30 visits per year of any combination of the following evidence-based therapies when available and medically appropriate. These therapies are only included on these lines if provided by a provider licensed to provide the therapy and when there is documentation of measurable clinically significant progress toward the therapy plan of care goals and objectives using evidence based objective tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
  • Rehabilitative therapy (physical and/or occupational therapy), if provided according to Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES. Rehabilitation services provided under this guideline also count towards visit totals in Guideline Note 6. Massage billed under CPT 97124 is included in this category and is subject to the restrictions on massage in Guideline Note 6.
  • Chiropractic or osteopathic manipulation
  • Acupuncture

Mechanical traction (CPT 97012) is not included on these lines, due to evidence of lack of effectiveness for treatment of back and neck conditions.

The development of this guideline note was informed by HERC coverage guidances on Low Back Pain Non-Pharmacologic, Non-Invasive Intervention, Low Back Pain, Pharmacological and Herbal Therapies. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx

GUIDELINE NOTE 60, OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE

Lines 346,​361,​402,​530

Opioid medications are only included on these lines under the following criteria. Time periods described below are relative to the patient’s initial injury or condition for which opioids were originally prescribed, regardless of whether the individual or any plan paid for the medication. Providers are encouraged to consider the recommendations of the Oregon Opioid Prescribing Guidelines Task Force when prescribing opioid medications: Oregon Acute Opioid Prescribing Guideline (October 2018) and the Oregon Chronic Opioid Prescribing Guidelines (2017-2018).

For acute conditions and flares

During the first 6 weeks after an acute injury, acute flare of chronic pain, or surgery opioid treatment is included on these lines ONLY:

  1. When each prescription is limited to 7 days of treatment, AND
  2. For short acting opioids only, AND
  3. When one or more alternative first line pharmacologic therapies such as NSAIDs, acetaminophen, and muscle relaxers have been tried and found not effective or are contraindicated, AND
  4. When prescribed with a plan to keep active (home or prescribed exercise regime) and with consideration of additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, AND
  5. There is documented evaluation of the patient’s risk factors for opioid misuse or abuse (e.g., history of opioid misuse, verification of prescription history in the PDMP).

During subacute period

Treatment with opioids after 6 weeks of continuous therapy and up to 90 days after the initial injury/flare/surgery is included on these lines ONLY:

  1. With documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
  2. When prescribed with a plan to keep active (home or prescribed exercise regime) and additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, when available.
  3. With verification that the patient is not high risk for opioid misuse or abuse. Such verification may involve
    • Documented verification from the state’s prescription monitoring program database that the controlled substance history is consistent with the prescribing record
    • Use of a validated screening instrument to verify the absence of a current substance use disorder (excluding nicotine) or a history of prior opioid misuse or abuse
    • Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids.
  4. Each prescription must be limited to 7 days of treatment and for short acting opioids only

Long-term opioid therapy

Long-term opioid treatment (>90 days) after the initial injury/flare/surgery is included on these lines as described below.

For patients receiving long-term opioid therapy (>90 days) for conditions of the back and spine, continued coverage of opioid medications requires a comprehensive individual treatment plan for chronic pain, taking into account the biological, behavioral, psychological and social factors which may influence each individual’s experience of chronic pain as well as any current and past treatments. Treatment plans should be prescribed (unless contraindicated) with a plan to keep active (home or prescribed exercise regimen) and should include additional therapies such as spinal manipulation, physical therapy, yoga or acupuncture unless contraindicated and if available in a patient’s community and reasonably accessible to the patient. The treatment plan should conform with the Oregon Chronic Opioid Prescribing Guidelines (2017-2018). A taper plan may be indicated if and when clinically appropriate.

Opioid tapers

Opioid taper plans are not required in order for continued inclusion of long-term opioid therapy on these lines. Providers initiating taper plans are encouraged to follow Oregon Opioid Tapering Guidelines (January 2020). Taper plans should include nonpharmacological treatment strategies for managing the patient’s pain. During the taper, behavioral health conditions need to be regularly assessed and appropriately managed.

GUIDELINE NOTE 135, FIBROMYALGIA

Line 531

Fibromyalgia (ICD-10-CM M79.7) treatment should consist of a multi-modal approach, which should include two of more of the following:

  1. medications other than opioids
  2. exercise advice/programs
  3. cognitive behavioral therapy.

Care should be provided in the primary care setting. Referrals to specialists are generally not required. Use of opioids should be avoided due to evidence of harm in this condition.

COPD

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Diabetes

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DVT

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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Drug Use Criteria

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GERD

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GUIDELINE NOTE 144, PROTON PUMP INHIBITOR THERAPY FOR GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Lines 314,​380,​513

Short term treatment (up to 8 weeks) of GERD without Barrett’s (ICD-10-CM K20.8, K20.9, K21.0, K21.9) with proton pump inhibitor therapy is included on Line 380.

Long term proton pump inhibitor therapy is included on Line 380 for Barrett’s esophagus (ICD-10-CM K22.70). Long term treatment is included on Line 513 and on Line 314 for Barrett’s esophagus with dysplasia (ICD-10-CM K22.71).

Heart Failure

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Hepatitis C

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Migraine

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Miscellaneous

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Multiple Sclerosis

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Narcolepsy

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Opioid Use Disorder

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GUIDELINE NOTE 175, MEDICATION-ASSISTED TREATMENT OF OPIOID DEPENDENCE

Lines 1,​4

In patients who meet criteria for opioid use disorder, programs that offer treatment of opioid use disorder must offer patients a variety of evidence-based interventions including behavioral interventions, social support, and Medication Assisted Treatment (MAT) and are individualized to the patient’s needs. Intensive programs, such as inpatient residential treatment programs, are required to inform patients about MAT and to offer access to and support for MAT (including at least one form of opioid substitution therapy) if patients elect to receive it, to be included on this line.

MAT includes pharmacotherapy with opioid substitution therapy (methadone and buprenorphine) and opioid antagonists (naltrexone).

Detoxification alone is likely ineffective for producing long-term benefit and should be followed by a formal substance use disorder individualized treatment plan.

In pregnant women with opioid dependence, comprehensive treatment (including opioid substitution therapy) is included on this line.

Overactive Bladder

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Seizures

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Severe Acne

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GUIDELINE NOTE 65, SEVERE CYSTIC ACNE

Lines 453,​522

Acne is only included on Line 453 if it is severe, defined as the presence of the following characteristics: persistent or recurrent inflammatory nodules and cysts AND ongoing scarring. Otherwise, acne diagnoses are included on Line 522.

Note that acne with recurrent abscesses or communicating sinuses is covered according to Guideline Note 132 ACNE CONGLOBATA AND ACNE FULMINANS.

Sinusitis

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Tobacco Cessation

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GUIDELINE NOTE 4, TOBACCO DEPENDENCE, INCLUDING DURING PREGNANCY

Lines 1,​5

Pharmacotherapy (including varenicline, buproprion and all five FDA-approved forms of nicotine-replacement therapy) and behavioral counseling are included on this line, alone or in combination, for at least two quit attempts per year. At least two quit attempts per year must be provided without prior authorization, and each attempt can include both pharmacotherapy and behavioral counseling.  Combination drug therapy (i.e. two forms of NRT or NRT plus buproprion) is also included with each quit attempt without prior authorization. However, nicotine inhalers and sprays may be subject to prior authorization.

A minimum of four counseling sessions of at least 10 minutes each (group or individual, telephonic or in person) are included for each quit attempt. More intensive interventions and group therapy are likely to be the most effective behavioral interventions. During pregnancy, additional intensive behavioral counseling is strongly encouraged. All tobacco cessation interventions during pregnancy are not subject to quantity or duration limits.

Inclusion on this line follows the minimum standard criteria as defined in the Oregon Public Health Division “Standard Tobacco Cessation Coverage” (based on the Patient Protection and Affordable Care Act), available here: https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/TOBACCOPREVENTION/Documents/tob_cessation_coverage_standards.pdf. The USPSTF has also made “A” recommendations for screening, counseling, and treatment of pregnant and nonpregnant adults, included in Guideline Note 106.

The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence-based-Reports.aspx