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Title: |
| Stimulant Medications Prior Authorization Criteria |
Program Objectives: |
| The intent of the prior authorization (PA) program for stimulant medications in adults is to promote appropriate utilization according to the FDA-approved indications and/or clinical studies and/or practice guidelines. Medications included are amphetamine salt combinations (Adderall®, Adderall® XR, generics), dexmethylphenidate (Focalin®, Focalin® XR), dextroamphetamine (Dexedrine®, Dextrostat®, generics), lisdexamfetamine (VyvanseTM), and methylphenidate (Concerta®, DaytranaTM, MetadateTM CD/ER, MethylinTM, Ritalin®, Ritalin® LA/SR, generics). This program applies only to members 20 years of age and older. |
Effective Date: |
| 03/08 for Oklahoma |
Prior Authorization Criteria For Approval: |
Amphetamine salt combinations (Adderall®, Adderall® XR, generics), dexmethylphenidate (Focalin®, Focalin® XR), dextroamphetamine (Dexedrine®, Dextrostat®, LiquaddTM, generics), lisdexamfetamine (VyvanseTM), methylphenidate (Concerta®, DaytranaTM, MetadateTM CD/ER, MethylinTM, Ritalin®, Ritalin® LA/SR, generics)
Initial and Renewal Evaluation
1. Are medications for the patient’s diagnosis a covered benefit for this member?
If yes, continue to 2.
If no, deny.
2. Is the patient’s diagnosis an FDA-labeled indication for the requested medication?
If yes, approve for 12 months.
If no, deny. |
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| CPT® only copyright 2003 American Medical Association. All Rights Reserved. | |
