Us Family Health Plan Pharmacy Program Medical Necessity Form For Vyvanse Page 2
Download a blank fillable Us Family Health Plan Pharmacy Program Medical Necessity Form For Vyvanse in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Us Family Health Plan Pharmacy Program Medical Necessity Form For Vyvanse with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Medical Necessity Criteria for Attention Deficit Hyperactivity Disorder (ADHD) Agents
All current and new users of nonformulary ADHD agents must meet one of the following criteria in order for
medical necessity to be approved:
1.
Use of ALL of the following formulary alternatives is contraindicated (e.g., due to hypersensitivity): extended
release methylphenidate (e.g., Concerta, Metadate CD, and Ritalin LA) and extended release mixed amphetamine
salts (Adderall XR).
2.
The patient has experienced or is likely to experience significant adverse effects from ALL of the following
formulary alternatives: extended release methylphenidate (e.g., Concerta, Metadate CD, and Ritalin LA) and
extended release mixed amphetamine salts (Adderall XR).
3.
Use of ALL of the following formulary alternatives has resulted in therapeutic failure: extended release
methylphenidate (e.g., Concerta, Metadate CD, and Ritalin LA) and extended release mixed amphetamine salts
(Adderall XR).
4.
(Daytrana patch only) - The patient is unable to take oral medications.
Medical necessity criteria for Daytrana, Focalin, and Focalin XR recommended by the DoD Pharmacy &
Therapeutics Committee at the Nov 2006 meeting & approved by the Director, TMA on 17 Jan 2007. Medical
necessity criteria for Vyvanse recommended by the DoD Pharmacy & Therapeutics Committee at the Nov 2007
meeting & approved by the Director, TMA on 13 February 2008. For more information, please see the
DoD P&T
Committee
minutes..
is the official Web site of the
TRICARE Management Activity,
a component of the
Military Health System
Skyline 5, Suite 810, 5111 Leesburg Pike,
Falls Church, VA 22041-3206
ADVERTISEMENT
0 votes
Related Articles
Related forms
Us Family Health Plan Pharmacy Program Medical Necessity Form For Daytrana, Focalin, Focalin Xr
Business
Tricare Pharmacy Program Medical Necessity Form For Targeted Immunomodulatory Biologics (tibs) - Cimzia, Enbrel, Kineret, Orencia Sq, Simponi
Business
Related Categories
Parent category: Business