PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ANTIPSYCHOTIC DRUGS FOR CHILDREN 3 of 5 8 YEARS OF AGE AND YOUNGER F-00556 (01/2018) SECTION VI MEDICATION USE (Continued) – 25. Indicate below the experience with psychoactive medication(s) other than the drug being requested. List the drugs and the child’s highest daily doses achieved that the child is currently taking and has taken in the past in the spaces provided. Drug Class Current Past Name(s) Name(s) Alpha-2 Adrenergic Agonist Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Name(s) Name(s) Antidepressant Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Name(s) Name(s) Antipsychotic Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Name(s) Name(s) Stimulant Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Name(s) Name(s) Anticonvulsant / Mood Stabilizer / Lithium / All Other Drug Classes Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved SECTION VII ADDITIONAL CLINICAL INFORMATION – 26. Indicate if the child has the following symptoms. 1. Symptom(s) of persistent irritability / anger (daily or nearly daily) Yes No 2. Symptom(s) of temper outbursts (three or more per week). Yes No 3. Symptom(s) of anxiety. Yes No If yes to symptoms of anxiety, describe below. Continued
PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ANTIPSYCHOTIC DRUGS FOR CHILDREN 3 of 5 8 YEARS OF AGE AND YOUNGER F-00556 (01/2018) SECTION VI – MEDICATION USE (Continued) 25. Indicate below the child’s experience with psychoactive medication(s) other than the drug being requested. List the drugs and the highest daily doses achieved that the child is currently taking and has taken in the past in the spaces provided. Drug Class Current Past Alpha-2 Adrenergic Agonist Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Antidepressant Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Antipsychotic Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Stimulant Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved Anticonvulsant / Mood Stabilizer / Lithium / All Other Drug Classes Name(s) Name(s) Highest Daily Dose(s) Achieved Highest Daily Dose(s) Achieved SECTION VII – ADDITIONAL CLINICAL INFORMATION 26. Indicate if the child has the following symptoms. 1. Symptom(s) of persistent irritability / anger (daily or nearly daily) Yes No 2. Symptom(s) of temper outbursts (three or more per week). Yes No 3. Symptom(s) of anxiety. Yes No If yes to symptoms of anxiety, describe below. Continued
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