COVERED USES:

FDA Approved Indications: Attention deficit hyperactivity disorder (ADHD).

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

Member is at least 6 years of age.

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

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

CRITERIA:

Trial and failure of at least 2 formulary agents (generic Adderall®, generic Dexedrine®, generic Ritalin®, generic Ritalin® SR, Adderall® XR, Concerta®, Metadate® CD, Ritalin® LA, and Strattera®)

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

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