COVERED USES:

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

Requests for a non-FDA approved ("off-label") indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

AGE RESTRICTIONS:

Daytrana® and Focalin® XR may be approved if member is at least 6 years of age and meets additional criteria.

PRESCRIBER RESTRICTIONS:

Prior authorization required unless prescribed by a Child Psychiatrist or Developmental Pediatrician.

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 is required. Formulary agents include 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 for up to one year.