Focalin XR — CareFirst (Caremark)
Narcolepsy
Initial criteria
- 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 being prescribed by, or in consultation with, a sleep specialist.
- Diagnosis of narcolepsy has been confirmed by a sleep study.
Reauthorization criteria
- 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.