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atomoxetine — CareFirst (Caremark)

Narcolepsy

Initial criteria

  • For ADHD or ADD: Patient has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)
  • The diagnosis has been appropriately documented (e.g., evaluated by a complete clinical assessment, using DSM-5, standardized rating scales, interviews/questionnaires)
  • If patient age ≤ 5 years, the patient continues to have ADHD/ADD symptoms despite participating in evidence-based behavioral therapy (e.g., parent training in behavior management, behavioral classroom interventions)
  • For Narcolepsy: The patient has a diagnosis of narcolepsy
  • Request is NOT for amphetamine extended-release (Adzenys ER, Adzenys XR-ODT), amphetamine-dextroamphetamine extended-release (Adderall XR), amphetamine sulfate orally disintegrating tablet (Evekeo ODT), methylphenidate chewable tablet, methylphenidate immediate release, methylphenidate extended-release (Aptensio XR, Concerta, Cotempla XR-ODT, methylphenidate CD, Methylphenidate Osmotic Extended-Release, Relexxii, Ritalin LA), dexmethylphenidate (Focalin), or dexmethylphenidate extended-release (Focalin XR)
  • The requested drug is being prescribed by, or in consultation with, a sleep specialist
  • The diagnosis of narcolepsy has been confirmed by a sleep study

Reauthorization criteria

  • For ADHD or ADD: Patient achieved or maintained improvement in signs and symptoms of ADHD/ADD from baseline
  • Patient’s need for continued therapy has been assessed within the previous year
  • For Narcolepsy: Request is NOT for amphetamine extended-release (Adzenys ER, Adzenys XR-ODT), amphetamine-dextroamphetamine extended-release (Adderall XR), amphetamine sulfate orally disintegrating tablet (Evekeo ODT), methylphenidate chewable tablet, methylphenidate immediate release, methylphenidate extended-release (Aptensio XR, Concerta, Cotempla XR-ODT, methylphenidate CD, Methylphenidate Osmotic Extended-Release, Relexxii, Ritalin LA), dexmethylphenidate (Focalin), or dexmethylphenidate extended-release (Focalin XR)
  • Patient has achieved or maintained improvement in daytime sleepiness with narcolepsy from baseline