Prior Authorization for stimulants is required for all tiers for members greater than 20 years of age and for members 0-4 years of age. All prior authorization requests for members under the age of 5 years must be reviewed by an OHCA contracted psychiatrist.
Tier 2 Prior Authorization Approval Criteria:
- A covered diagnosis; AND
- A previously failed trial with at least one long-acting Tier-1 stimulant that resulted in an inadequate response:
- Trials should have been within the last 180 days; AND
- Trials should have been dosed up to maximum recommended dose or documented adverse effects at higher doses should be included; AND
- If trials are not in member’s claim history, the pharmacy profile should be submitted or detailed information regarding dates and doses should be included along with the signature from the physician.
- Kapvay® [Clonidine Extended-Release (ER) Tablet] Approval Criteria:
- An FDA approved diagnosis; and
- Previously failed trials (within the last 180 days) with a long-acting Tier-1 stimulant, Intuniv®, and Strattera®, unless contraindicated, that did not yield adequate results; and
- A patient-specific, clinically significant reason why the member cannot use clonidine immediate-release tablets must be provided.
Tier 3 Prior Authorization Approval Criteria:
- A covered diagnosis; AND
- A previously failed trial with at least one long-acting Tier-1 stimulant that resulted in an inadequate response; AND
- A previously failed trial with at least one Tier-2 stimulant that resulted in an inadequate response:
- Trials should have been within the last 365 days; AND
- Trials should have been dosed up to maximum recommended dose or documented adverse effects at higher doses should be included; AND
- If trials are not in member’s claim history, the pharmacy profile should be submitted or detailed information regarding dates and doses should be included along with the signature from the physician.
- A clinical exception may apply for special formulation products when there is a patient-specific, clinically significant reason why member cannot use the available long acting capsule formulation.
- Qelbree™ [Viloxazine Extended-Release (ER) Capsule] Approval Criteria:
- An FDA approved diagnosis; and
- Member must be 6 to 17 years of age; and
- Previously failed trials (within the last 365 days) with a long-acting Tier-1 stimulant, a long-acting Tier-2 stimulant, Intuniv®, Strattera®, and Kapvay®, unless contraindicated, that did not yield adequate results; and
- Member must not be taking a monoamine oxidase inhibitor (MAOI) or have taken an MAOI within the last 14 days; and
- Member must not be taking sensitive CYP1A2 substrates or CYP1A2 substrates with a narrow therapeutic range (e.g., alosetron, duloxetine, ramelteon, tasimelteon, tizanidine, theophylline) concomitantly with Qelbree™; and
- A quantity limit of 30 capsules per 30 days will apply for the 100mg and 150mg strengths and 60 capsules per 30 days will apply for the 200mg strength.
- For Quillivant XR®, an age restriction of 10 years and younger will apply. Members older than 10 years of age will require a patient-specific, clinically significant reason why a special formulation product is needed.
Special Prior Authorization Approval Criteria:
Desoxyn®, Dexedrine®, Dexedrine Spansules®, Evekeo®, ProCentra®and Zenzedi® Criteria:
- Covered diagnosis; AND
- A patient-specific, clinically significant reason why member cannot use all other available stimulant medications.
Adzenys XR-ODT™, Adzenys ER™ Suspension, Cotempla XR-ODT™, Dyanavel™ XR, and Evekeo ODT™ Approval Criteria:
- FDA approved diagnosis; AND
- A patient-specific, clinically significant reason why member cannot use all other available formulations of stimulant medications that can be used for members who cannot swallow capsules/tablets; AND
- An age restriction of ten years and younger will apply. Members older than ten years of age will require a patient-specific, clinically significant reason why a special formulation product is needed.
Methylin® Chewable Tablets Criteria:
- A covered diagnosis; AND
- A patient-specific, clinically significant reason why the member cannot use methylphenidate immediate-release tablets must be provided; AND
- An age restriction of 10 years and younger will apply. Members older than 10 years of age will require a patient-specific, clinically significant reason why a special formulation product is needed.
Mydayis™ Criteria:
- An FDA approved diagnosis; AND
- Member must be 13 years of age or older; AND
- A patient-specific, clinically significant reason why the member cannot use all other available stimulant medications.
Narcolepsy Medications Approval Criteria:
- An FDA approved diagnosis; AND
- Use of Nuvigil® requires a patient-specific, clinically significant reason why the member cannot use stimulant medications to improve wakefulness during the daytime; AND
- Nuvigil® is brand name preferred due to net cost after rebates; however, brand name preferred status may be removed if the net cost changes and brand name is more costly than generic;AND
- Use of Provigil® (modafinil) requires a previously failed trial (within the last 180 days) with Nuvigil® and a patient-specific, clinically significant reason why the member cannot use stimulant medications to improve wakefulness during the daytime; AND
- Use of Sunosi® (solriamfetol), Wakix® (pitolisant), Xyrem® (sodium oxybate), or Xywav® (calcium/magnesium/potassium/sodium oxybates) requires previously failed trials (within the last 180 days) with Tier-1 and Tier-2 stimulants from different chemical categories, Provigil®, and Nuvigil®, unless contraindicated, that did not yield adequate results; and
- Additionally, use of Xywav® (calcium/magnesium/potassium/sodium oxybates) requires a patient-specific, clinically significant reason why the member cannot use Xyrem®; and
- For members requesting Xywav® due to lower sodium content in comparison to Xyrem®, a patient-specific, clinically significant reason why the member requires a low-sodium product must be provided; and
- The diagnosis of obstructive sleep apnea (OSA) requires concurrent treatment for the obstructive sleep apnea.
- The diagnosis of shift work sleep disorder requires the member’s work schedule to be included with the prior authorization request.
ADHD & Narcolepsy Medications Additional Criteria:
- Doses exceeding 1.5 times the FDA maximum are not covered.
- Prior Authorization is required for all tiers for members greater than 20 years of age and for members 0-4 years of age. All prior authorization requests for members under the age of 5 years must be reviewed by an OHCA contracted psychiatrist.
- For Daytrana® and Methylin® oral solution, an age restriction of 10 years and younger will apply. Members older than 10 years of age will require a patient-specific, clinically significant reason why a special formulation product is needed.
- Vyvanse® (Lisdexamfetamine) Approval Criteria: Binge Eating Disorder (BED)
- An FDA approved diagnosis of moderate-to-severe binge eating disorder; AND
- Member must be 18 years or older; AND
- Vyvanse® for the diagnosis of BED must be prescribed by a psychiatrist; AND
- Authorizations will not be granted for the purpose of weight loss without the diagnosis of BED or for the diagnosis of obesity alone. The safety and effectiveness of Vyvanse® for the treatment of obesity have not been established; AND
- A quantity limit of 30 capsules per 30 days will apply; AND
- Initial approvals will be for the duration of three months. Continued authorization will require prescriber documentation of improved response/effectiveness of Vyvanse®.
Second Opinion Process for Children 0-4 Years of Age and Unusual Dosing Requests |
Children less than 5 years of age will require a "second opinion" prior authorization to be reviewed by an OHCA-contracted child psychiatrist. Current users will be allowed to remain on current medication until the petition is submitted and reviewed. The second opinion process is as follows:
- Clinical pharmacist reviews petition for necessary information including diagnosis and behavioral information to submit to on-call OHCA psychiatrist.
- On-call psychiatrist at OHCA reviews submitted prior authorization request.
- OHCA faxes response back within 24 hours.
- Clinical pharmacist issues appropriate response for petition based on the results.
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adhd tier chart |
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Tier-1* |
Tier-2* |
Tier-3* |
Special PA |
Amphetamine Short-Acting |
Adzenys ER™ (amphetamine extended-release oral suspension) |
Adderall® (amphetamine/ dextroamphetamine) |
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Adzenys XR-ODT™ (amphetamine ER-ODT) |
Amphetamine Long-Acting |
amphetamine ER susp (Dyanavel® XR) |
amphetamine/ dextroamphetamine ER (Adderall XR®)
lisdexamfetamine cap and chew tab (Vyvanse®)+
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amphetamine (Evekeo®) |
Methylphenidate Short-Acting |
amphetamine ODT (Evekeo ODT™) |
Focalin® (dexmethylphenidate) |
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amphetamine/ dextroamphetamine ER (Mydayis®) |
Methylin® (methylphenidate) |
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dextroamphetamine (Dexedrine®) |
methylphenidate solution |
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dextroamphetamine ER (Dexedrine Spansules®) |
Ritalin® (methylphenidate)± |
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dextroamphetamine soln (ProCentra®) |
Methylphenidate Long-Acting |
dextroamphetamine (Zenzedi®) |
Focalin XR® (dexmethylphenidate ER) BRAND PREFERRED |
dexmethylphenidate ER (generic Focalin XR®) |
Adhansia XR™ (methylphenidate ER) |
methamphetamine (Desoxyn®) |
Metadate CD® (methylphenidate ER) |
methylphenidate ER (generic Concerta®) |
Aptensio XR™ (methylphenidate ER) |
methylphenidate ER ODT (Cotempla XR-ODT®) |
QuilliChew ER™ (methylphenidate ER chew tabs) |
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Jornay™ PM (methylphenidate ER) |
methylphenidate chew tab (Methylin®) |
Ritalin LA® (methylphenidate ER) |
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methylphenidate ER 72mg - generic |
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methylphenidate ER (Ritalin SR®) |
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methylphenidate ER susp (Quillivant XR®) |
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methylphenidate ER (Metadate ER®) |
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serdexmethylphen-idate/dexmethylphe-nidate (Azstarys™) |
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methylphenidate ER (Methylin ER®) |
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Non-Stimulants |
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Intuniv® (guanfacine ER) |
clonidine ER (Kapvay®)∆ |
viloxazine (Qelbree™)∆ |
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Strattera® (atomoxetine) |
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+Unique criteria applies for the diagnosis of binge eating disorder (BED).
∆Unique criteria applies in addition to tier trial requirements.
ADHD = attention-deficit/hyperactivity disorder; cap = capsule; chew tab = chewable tablet;
ER = extended-release; ODT = orally disintegrating tablet; PA = prior authorization; soln = solution; susp = suspension; tab = tablet
SECOBARBITAL (SECONAL SODIUM™) |
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Seconal Sodium™ (Secobarbital Sodium Capsule) Approval Criteria:
- An FDA approved indication for 1 of the following:
- The short-term treatment of insomnia; OR
- A preanesthetic; AND
- A patient-specific, clinically significant reason why the member cannot use other cost-effective therapeutic alternatives must be provided; AND
or the short-term treatment of insomnia, a quantity limit of 1 capsule per day not to exceed 14 capsules per 30 days will apply.
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ROPINIROLE (REQUIP XL®) AND PRAMIPEXOLE (MIRAPEX ER®) |
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PA criteria:
- Diagnosis of Parkinson's Disease, and
- Clinically significant reason why the immediate release products cannot be used.
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DROXIDOPA (NORTHERA™) |
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PA criteria:
- An FDA approved diagnosis of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure (Parkinson's disease, multiple system atrophy, and pure autonomic failure), dopamine beta-hydroxylase deficiency, or non-diabetic autonomic neuropathy; AND
- Member must be 18 years of age or older; AND
- Member must have tried and failed two of the following medications at recommended dosing within the last 90 days:
- Midodrine; OR
- Fludrocortisone; OR
- Pyridostigmine; OR
- Have a contraindication to all preferred medications.
- Initial approval will be for the duration of two weeks of treatment only.
- Continued approval will require the prescriber to provide information regarding improved member response/effectiveness of this medication to determine whether Northera™ is continuing to provide a benefit.
- Continued approval will be for the duration of three months. Each approval will require prescriber documentation of member response/effectiveness to Northera™.
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