Cotempla XR-ODT — CareFirst (Caremark)
Narcolepsy
Initial criteria
- Authorization may be granted when the patient has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD) when ALL of the following criteria are met:
- • The diagnosis has been appropriately documented (e.g., evaluated by a complete clinical assessment, using DSM-5, standardized rating scales, interviews/questionnaires).
- • If the patient is 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 (PTBM), behavioral classroom interventions).
- For Narcolepsy: Authorization may be granted when the patient has a diagnosis of narcolepsy when ALL of the following criteria are met:
- • This 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 has been confirmed by a sleep study.
Reauthorization criteria
- For ADHD/ADD: Authorization may be granted when the patient has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD) when ALL of the following criteria are met:
- • The patient achieved or maintained improvement in their signs and symptoms of ADHD/ADD from baseline.
- • The patient’s need for continued therapy has been assessed within the previous year.
- For Narcolepsy: Authorization may be granted when the patient has a diagnosis of narcolepsy when ALL of the following criteria are met:
- • This 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 patient has achieved or maintained improvement in daytime sleepiness with narcolepsy from baseline.