Limited Coverage Drugs – Atomoxetine

Generic Name

atomoxetine

Strength

10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

Form

capsule

Special Authority Criteria

Approval Period

For patients 6 to 18 years of age diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) with hyperactivity, impulsivity, or inattention that interfere with functioning

PLUS

  • Patient has been previously tried on both methylphenidate
    AND an amphetamine with unsatisfactory results or intolerance*

OR

  • Patient has contraindication(s) to stimulants.

* See Special Notes below

Up to the patient's 19th birthday.

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • Unsatisfactory trial of or intolerance to both methylphenidate AND an amphetamine: defined as no demonstrated effectiveness for symptoms of ADHD or functional impairment secondary to ADHD after a minimum 1 week trial of an adequate dose of both methylphenidate AND an amphetamine. At least one trial must be with an extended-release/long-acting stimulant. Specific details of drug, dose and duration tried, and unsatisfactory response are required, as applicable.
  • Specific details of medication intolerance or contraindication must be included in the Special Authority Request.
  • Coverage is not intended for "performance enhancement" in children or youth who do not have symptoms or functional impairment.

Special Authority Request Forms