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 years of age and older diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) with hyperactivity, impulsivity, or inattention that interfere with functioning PLUS
OR
* See Special Notes below |
Indefinite |
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 patients who do not have symptoms or functional impairment.