Limited coverage criteria – atomoxetine

Last updated on March 17, 2025

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Generic name	atomoxetine
Strength & form	10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg 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 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	Indefinite

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

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

Patient has contraindication(s) to stimulants

* See Special notes below

Indefinite

Practitioner exemptions

None

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
Criteria applicable to all plans, including Plan G

Special Authority request form(s)

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