Limited coverage criteria – methylphenidate extended-release

Last updated on March 19, 2025

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Generic name	methylphenidate extended-release
Strength & form	18 mg/27 mg/36 mg/54 mg extended-release tablet

Special Authority criteria	Approval period
For the treatment of attention deficit hyperactivity disorder (ADHD) in patients 6 years of age and older who require 12 hours of continuous coverage for hyperactivity, impulsivity, or inattention that interferes with functioning AND have been previously tried on one of the following with unsatisfactory results¹ or intolerance: Immediate‑release or sustained-release methylphenidate OR Immediate-release or sustained-release dextroamphetamine	Indefinite

Special Authority criteria

Approval period

For the treatment of attention deficit hyperactivity disorder (ADHD) in patients 6 years of age and older who require 12 hours of continuous coverage for hyperactivity, impulsivity, or inattention that interferes with functioning AND have been previously tried on one of the following with unsatisfactory results¹ or intolerance:

Immediate‑release or sustained-release methylphenidate

Immediate-release or sustained-release dextroamphetamine

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 1 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

Special Authority request form(s)

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