Us Family Health Plan Pharmacy Program Medical Necessity Form For Daytrana, Focalin, Focalin Xr Page 3
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3US Family Health Plan Pharmacy Program Medical
Necessity Form for Daytrana, Focalin, Focalin XR
This form applies to the US Family Health Plan Mail Order Pharmacy and the US Family Health Plan Retail Pharmacy programs. This form must be completed and signed by
the prescriber.
Formulary medications for Attention-Deficit / Hyperactivity Disorder (ADHD) include Adderall immediate-release and Adderall XR and
generics, Concerta and generics, Metadate CD, Ritalin LA, Strattera, immediate/sustained release methylphenidate, dextroamphetamine,
and methamphetamine. Daytrana (methylphenidate patch), Focalin (immediate release dexmethylphenidate), Focalin XR (extended release
dexmethylphenidate), and Vyvanse (lisdexamfetamine) are non-formulary, but available to most beneficiaries at the non-formulary cost share.
NOTE: This form applies to Daytrana, Focalin, and Focalin XR. A separate form applies to Vyvanse.
You do NOT need to complete this form in order for non-active duty beneficiaries (spouses, dependents, and retirees) to obtain Daytrana, Focalin, or
Focalin XR at the non-formulary cost share. The purpose of this form is to provide information that will be used to determine if the use of a non-
formulary medication instead of a formulary medication is medically necessary. If Daytrana, Focalin, or Focalin XR is determined to be medically
necessary, non-active duty beneficiaries may obtain it at the formulary cost share.
• The provider may call:
or the completed form may be faxed to:
• The patient may attach the completed form to the prescription and mail
it to: ATTN: Pharmacy, 77 Warren St, Brighton, MA 02135
Step
Please complete patient and physician information (Please print)
1
Patient Name:
Physician Name:
Address:
Address:
Sponsor ID #
Phone #:
Date of Birth:
Secure Fax #:
Step
Non-formulary medication requested:
□ Dexmethylphenidate products (Focalin, Focalin XR)
□ Methylphenidate patch (Daytrana)
2
Please explain why the patient cannot be treated with the formulary medications. Circle a reason code if applicable.
You MUST supply a specific written clinical explanation as to why each of the formulary medications would be
unacceptable
.
Formulary Alternative
Reason
Clinical Explanation
Extended release methylphenidate
1 2 3 4
(e.g., Concerta, Metadate CD, Ritalin LA)
Extended release mixed amphetamine
1 2 3 4
salts (Adderall XR)
Note: The formulary alternatives listed above only include the extended release stimulant products. In most cases, Focalin
(dexmethylphenidate immediate release) would be used for dose titration or to supplement the use of Focalin XR, not as a sole therapy;
therefore, medical necessity review is based on the extended release stimulant products. Approved medical necessity determinations for
dexmethylphenidate products will apply to both Focalin and Focalin XR
.
Acceptable clinical reasons for not using a formulary alternative are:
1. Use of the formulary alternative is contraindicated (e.g., due to hypersensitivity).
2. The patient has experienced or is likely to experience significant adverse effects from the formulary alternative.
3. Use of the formulary alternative has resulted in therapeutic failure.
Daytrana patch only – the patient is unable to take oral medications.
4.
Step
I certify the above is true to the best of my knowledge. Please sign and date:
3
Prescriber Signature
Date
Latest revision: September 28, 2011
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