Stimulants And Related Agents Prior Authorization Form

Office of Medical Assistance Programs

Fee-for-Service, Pharmacy Division

Phone 1-800-537-8862 Fax 1-866-327-0191

STIMULANTS AND RELATED AGENTS

PRIOR AUTHORIZATION FORM

To review the prior authorization guidelines for Stimulants and Related Agents, please refer to Medical Assistance Prior Authorization of Pharmaceutical Services

Handbook Chapter – Stimulants and Related Agents at

PRIOR AUTHORIZATION REQUEST INFORMATION

PRESCRIBER INFORMATION

New request

Additional info (PA#:____________________)

Prescriber name

Renewal request

# of pages in request: _____________________

& specialty:

Name/phone # of

office contact:

State license #:

NPI:

LTC facility contact/phone:

Street address:

Recipient Name:

Suite #:

City/state/zip:

Recipient ID#:

DOB:

Phone:

Fax:

CLINICAL INFORMATION

Medication Requested

(Names in parentheses are the brand name equivalents for reference purposes. IR = immediate-release; ER/XR = extended-release)

Preferred Agents

Non-Preferred Agents

Adderall tablet

methylphenidate IR tablet

Aptensio XR capsule

dextroamphetamine sol’n

methylphenidate chew (Methylin)

Adderall XR

(Ritalin)

clonidine ER tablet (Kapvay)

(ProCentra)

methylphenidate CD capsule

amphetamine mixed

methylphenidate ER/SR

Concerta tablet

dextroamp/amphetamine

(Metadate CD)

salts IR tablet (Adderall)

tablet (Ritalin-SR)

Desoxyn tablet

mixed salts combo XR

methylphenidate ER capsule

Daytrana patch

methylphenidate ER 24-

Dexedrine Spansule ER

capsule (Adderall XR)

(Ritalin LA)

dextroamphetamine IR

hour tab (Concerta) (AHP &

Dexedrine IR tablet

Evekeo tablet

methylphenidate solution

tablet (Dexedrine IR,

Actavis manufacturers only)

dexmethylphenidate IR tablet (Focalin)

Intuniv tablet

(Methylin)

Dextrostat)

Quillivant XR suspension

dexmethylphenidate XR cap (Focalin XR)

Kapvay tablet

ProCentra solution

Focalin tablet

Strattera capsule

dextroamphetamine ER cap (Dexedrine

methamphetamine tablet

Ritalin tablet

Focalin XR capsule

Vyvanse capsule

Spansule)

Methylin chewable

Ritalin LA capsule

Metadate CD capsule

Methylin solution

Zenzedi tablet

Strength:

Directions:

Quantity:

# months requested:

Diagnosis:

Diagnosis code (required):

Request for a Non-Preferred Agent:

Yes – submit documentation of drug regimens failed,

1. Does the Recipient have a history of trial and failure, contraindication, or intolerance to the preferred

contraindications, and intolerances

Stimulants & Related Agents (listed above)?

No

Request for a Recipient LESS than 4 Years of Age:

Yes – Submit documentation of diagnosis.

1. Does the Recipient have one of the following diagnoses? Check all that apply.

No – Submit medical literature supporting the use of the

ADD

ADHD

Autism

Brain injury

requested medication for the Recipient’s age and diagnosis

2. Is the requested medication prescribed by, or in consultation with, one of the following specialists?

Yes

Pediatric Neurologist

Child/Adolescent Psychiatrist

Child Development Pediatrician

No (prescriber’s specialty: ________________________)

3. Has the Recipient had a comprehensive evaluation by, or in conjunction with, the above specialist?

Yes – submit documentation of evaluation

No

4. Strattera requests: What is the Recipient’s weight?

weight: ___________ lbs / kg

date: __________________

Request for a Recipient 18 Years of Age and Older:

ADD/ADHD

Initial request – submit documentation of an initial evaluation that shows a history of symptoms that meet the current

DSM criteria (note: a rating scale alone is not sufficient documentation)

Renewal request – submit documentation supporting the continued need for the medication to manage symptoms

Narcolepsy – submit documentation of Recipient’s symptom history and results of an overnight sleep study (a PSG) AND a Multiple

1. What is the Recipient’s

Sleep Latency Test (MSLT)

diagnosis?

Moderate to Severe Binge Eating Disorder (Vyvanse request)

Initial request – submit documentation of ALL of the following: an initial evaluation that shows a history of symptoms

that meet the current DSM criteria; if the Recipient does NOT have ADD/ADHD, the Recipient has tried, or cannot try,

SSRIs or topiramate, AND an offer of referral for cognitive behavioral therapy or other psychotherapy

Renewal request – submit documentation that the Recipient experienced a reduction in binge eating

2. Stimulant requests: Does the Recipient have a history of or currently have substance use disorder [SUD]

Yes

submit documentation of a recent evaluation

(drugs OR alcohol)?

No

for current or past substance use

3. For Recipients with a history of or current SUD, does the Recipient have documentation of active

Yes – submit documentation of treatment

participation in, or successful completion of, a substance use disorder treatment program?

No or N/A

4. For Recipients with a history of or current SUD, does the Recipient have documentation of a recent urine

Yes – submit documentation of test results

drug screen (UDS) that is negative for non-prescribed benzodiazepines, opiates, and illicit drugs?

No or N/A

PLEASE FAX COMPLETED FORM WITH REQUIRED CLINICAL DOCUMENTATION TO DHS – PHARMACY DIVISION

Prescriber Signature:

Date:

Confidentiality Notice: The documents accompanying this telecopy may contain confidential information belonging to the sender. The information is intended only for the use of the

individual named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any telecopy is strictly prohibited.

Form effective 1/20/16