COVERED USES:

FDA Approved Indications: Attention-Deficit/Hyperactivity Disorder (ADHD)

All FDA-approved indications unless otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

To obtain a prior authorization for atomoxetine, one or more of the following criteria must be met:

1. Stimulant therapy has failed
2. A documented contraindication, allergy, sensitivity, or adverse reaction to stimulants
3. Severe motor tics or tics exacerbated by stimulants
4. History of drug abuse or danger of diversion in the home
5. Prescribed by a child psychiatrist or Developmental psychiatrist

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.