Requests by the FDA. For authorization of a brand name medication, please submit a copy of the FDA Indefinite MedWatch form detailing trial and failure of, or intolerance/adverse side effect to generic formulations made by 2 different manufacturers. The completed form should also be submitted to the FDA. The FDA MedWatch form is available at: Medication Authorization Guidelines/Criteria Initial ADHD Medication PA is required for members who are <6 years old and >18 years old. year Age Limits Last reviewed: 06/01/15 Criteria for < 6 years old: Diagnosis of ADHD AND Amphetamine mixed Documentation stating that psychosocial issues and non-medical interventions are being addressed by the clinical team AND salts IR/LA The requested dose is NOT greater than FDA recommended maximum daily dosage Daytrana Patients who are >18 years old must have ONE of the following diagnoses: Dextroamphetamine ADHD IR/LA Narcolepsy (for methylphenidate, amphetamine/dextroamphetamine, or dextroamphetamine) Cancer-related fatigue (for methylphenidate) methylin Fatigue due MS (for methylphenidate) methylphenidate Idiopathic hypersomnia (for methylphenidate, amphetamine/dextroamphetamine, or dextroamphetamine) IR/CR/ER dexmethylphenidate IR/ER Vyvanse Methamphetamine Advair Advair Diskus will process for children 4-11 years old without PA. Prescriptions for patients outside of this age range will require a PA Initial Last reviewed: 06/24/15 and documented failure or intolerance to Symbicort.
Requests by the FDA. For authorization of a brand name medication, please submit a copy of the FDA MedWatch form detailing trial and failure of, or intolerance/adverse side effect to generic formulations made by 2 different manufacturers. The completed form should also be submitted to the FDA. The FDA MedWatch form is available at: Indefinite Medication Authorization Guidelines/Criteria ADHD Medication Age Limits Last reviewed: 06/01/15 Amphetamine mixed salts IR/LA Daytrana Dextroamphetamine IR/LA methylin methylphenidate IR/CR/ER dexmethylphenidate IR/ER Vyvanse Methamphetamine PA is required for members who are <6 years old and >18 years old. Criteria for < 6 years old: Diagnosis of ADHD AND Documentation stating that psychosocial issues and non-medical interventions are being addressed by the clinical team AND The requested dose is NOT greater than FDA recommended maximum daily dosage Patients who are >18 years old must have ONE of the following diagnoses: ADHD Narcolepsy (for methylphenidate, amphetamine/dextroamphetamine, or dextroamphetamine) Cancer-related fatigue (for methylphenidate) Fatigue due MS (for methylphenidate) Idiopathic hypersomnia (for methylphenidate, amphetamine/dextroamphetamine, or dextroamphetamine) Initial year Advair Last reviewed: 06/24/15 Advair Diskus will process for children 4-11 years old without PA. Prescriptions for patients outside of this age range will require a PA and documented failure or intolerance to Symbicort. Initial
2016%20Illinois%20Medicaid%20PA%20Guideline%20Chart.v5.docx