Qelbree — Medical Mutual

Initial criteria

• Prescribed by or in consultation with a physician who specializes in the condition being treated
• Patient age ≥ 6 years
• Patient has tried at least one generic stimulant (e.g., methylphenidate, amphetamine) OR patient cannot use stimulants due to history of drug addiction, decreased appetite in children, growth restriction/suppression in children, unexplained/unexpected weight loss, etc.
• Patient has tried at least one generic non-stimulant medication (e.g., atomoxetine, guanfacine ER, clonidine ER) OR patient has a documented inability to swallow tablets/capsules [documentation required]

Reauthorization criteria

• Response to therapy is required for continuation of therapy

Approval duration

1 year initial, 1 year reauth