COVERED USES:

FDA Approved Indications: Attention Deficit Hyperactivity Disorder (ADHD) and narcolepsy.

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:

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 will be for up to one year. Reauthorization will be for up to one year.