dextroamphetamine (all other brands) — CareFirst (Caremark)
Narcolepsy
Initial criteria
- For ADHD or ADD: 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, symptoms persist despite participation in evidence-based behavioral therapy (e.g., parent training in behavior management, behavioral classroom interventions).
- 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).
- Requested drug is prescribed by, or in consultation with, a sleep specialist.
- Diagnosis of narcolepsy 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 achieved or maintained improvement in daytime sleepiness with narcolepsy from baseline.