Prior authorization criteria for:
CNS Stimulant Agents
Generic Adderall® and Dexedrine®
COVERED USES:
FDA Approved Indications: Attention Deficit Hyperactivity Disorder (ADHD) and narcolepsy.
All FDA-approved indications not 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:
Documentation that medical benefits exceed the risks associated with these medications.
EXCLUSION CRITERIA:
NA
COVERAGE DURATION:
Initial authorization and reauthorization will be approved for up to one year.