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.

THIS SECTION IS CURRENTLY UNDER CONSTRUCTION

Attention Deficit/Hyperactivity Disorders in Children

Guideline Note

Prioritized List Guideline Note
Extracted from the February 1, 2021 Prioritized List
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/DSIHERC/Pages/Evidence-based-Reports.aspx
https://www.oregon.gov/oha/HPA/DSI-HERC/PrioritizedList/2-1-

Short Acting Stimulant Drug Use Criteria

Colony Stimulating Factors

Guideline Note

Drug Use Criteria