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methylphenidate — CareFirst (Caremark)

Attention Deficit Disorder (ADD)

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, behavioral classroom interventions).

Reauthorization 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 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.