Limited coverage criteria – methylphenidate
Last updated on July 23, 2025
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Generic name |
methylphenidate |
|
|---|---|---|
Brand name |
Strength |
Form |
| Foquest | 25 mg, 35 mg, 45 mg, 55 mg, 70 mg, 85 mg, 100 mg | controlled-release capsule |
| Concerta, generics | 18 mg, 27 mg, 36 mg, 54 mg | extended-release tablet |
Special Authority criteria |
Approval period |
|
|
For patients 6 years of age and older diagnosed with attention-deficit hyperactivity disorder (ADHD) requiring 12 hours of continuous coverage for hyperactivity, impulsivity, or inattention that interferes with functioning who have previously tried one of the following therapies with unsatisfactory results1 or intolerance:
OR
|
Indefinite | |
Practitioner exemptions
- None
Special notes
- 1"Unsatisfactory results" is defined as no demonstrated effectiveness for symptoms of ADHD or functional impairment secondary to ADHD after a minimum one-week trial of an adequate dose of immediate-release or sustained-release medication. Specific details of drug, dose and duration tried, and unsatisfactory response are required, as applicable
- 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