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methylphenidate (all other brands) — CareFirst (Caremark)

Attention Deficit Disorder (ADD)

Initial criteria

  • For ADHD or ADD: Authorization may be granted when the patient has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD) and ALL of the following criteria are met:
  • - The diagnosis has been appropriately documented (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, behavioral classroom interventions).
  • For Narcolepsy: Authorization may be granted when the patient has a diagnosis of narcolepsy and 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 or ADD: Authorization may be granted when the patient has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD) and 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 and 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.