Qelbree — Medical Mutual

Initial criteria

• Patient age ≥ 6 years; AND
• One of the following conditions is met (i OR ii OR iii OR iv OR v):
• i. The request is for a generic product (atomoxetine, guanfacine ER, or clonidine ER); OR
• ii. If the request is for brand name Strattera, the patient has tried generic atomoxetine AND brand Strattera is being requested due to a formulation difference in inactive ingredient(s) [e.g. dyes, fillers, preservatives] which, per the prescriber, would result in a significant allergy or serious adverse reaction; OR
• iii. If the request is for brand name Intuniv, the patient has tried generic guanfacine ER AND brand Intuniv is being requested due to a formulation difference in inactive ingredient(s) [e.g. dyes, fillers, preservatives] which, per the prescriber, would result in a significant allergy or serious adverse reaction; OR
• iv. If the request is for brand name Kapvay, the patient has tried generic clonidine ER AND brand Kapvay is being requested due to a formulation difference in inactive ingredient(s) [e.g. dyes, fillers, preservatives] which, per the prescriber, would result in a significant allergy or serious adverse reaction; OR
• v. If the request is for Qelbree, the patient has tried at least one generic stimulant medication (e.g. methylphenidate) AND at least one generic non-stimulant medication (e.g. atomoxetine, guanfacine ER, clonidine ER).

Reauthorization criteria

• Response to therapy is required for continuation of therapy.

Approval duration

1 year