ATTENTION- DEFICIT HYPERACTIVITY DISORDER (ADHD) PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state] CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX PRESCRIBER ADDRESS CITY STATE ZIP Formulary Drug? Yes No PATIENT NAME Blue Cross NC ID DATE OF BIRTH GENDER REQUEST FOR RESTRICTED ACCESS ADHD MEDICATION Diagnosis Code:. Please check the box of the restricted access medication you are requesting: Brand Adderall Tablets Brand Focalin Methylphenidate chews Brand Ritalin Adzenys ER Brand Focalin XR Methylphenidate ER Brand Ritalin LA (suspension) Osmotic Release Adzenys XR-ODT TM Brand Intuniv Mydayis Brand Ritalin SR Aptensio XR Brand Kapvay Brand Procentra Strattera Daytrana Brand Metadate CD Quillichew ER Vyvanse Brand Dexedrine XR Brand Methylin Quillivant XR Brand Zenzedi Dyanavel XR. Please list any medications the member has tried and failed, or has a contraindication/intolerance to for this diagnosis: **Please see pages 4 for FDA approved labeling dosing which does NOT require review** REQUEST FOR QUANTITY LIMIT EXCEPTION FOR ADHD MEDICATION Diagnosis Code: Medication Name and Strength: Requested Quantity per day: ***Please enter quantity as a numeric value with one decimal place (ex..0,.5)*** In the space provided, please document support for the requested Quantity Limit Exception (this may include documented clinical rationale and/or medical records). If none, write N/A. Please certify the following by signing and dating below: I certify that I have been authorized to request prior review and certification for the above requested service(s). I further certify that my patient s medical records accurately reflect the information provided. I understand that Blue Cross NC may request medical records for this patient at any time in order to verify this information. I further understand that if Blue Cross NC determines this information is not reflected in my patient s medical records, Blue Cross NC may request a refund of any payments made and/or pursue any other remedies available. Prescriber s Signature (Required): Date:. For Blue Cross NC members, fax form to -800-795-9403 M F Last Revision Date: April 08 Page
Medication QUANTITY LIMITS Quantity per Day (unless specified) Max Daily Dose/Maximum Dose Studied Per FDA Label dextroamphetamine) 5mg dextroamphetamine) 7.5mg dextroamphetamine) 0mg dextroamphetamine).5mg dextroamphetamine) 5mg dextroamphetamine) 0mg dextroamphetamine) 30mg release) 5mg release) 0mg release) 5mg release) 0mg release) 5mg release) 30mg 3 ADHD (Pediatric and Adults): Not to exceed 3 40mg/day except only in rare cases 3 Narcolepsy: 60mg/day in 3 divided doses 3 Pediatric (6-7 yoa): 0mg to 40mg per day studied; no adequate evidence that doses greater than 0mg/day conferred additional benefit Adults: 0mg to 60mg per day studied; no adequate evidence that doses greater than 0mg/day conferred additional benefit Adzenys ER (amphetamine ER suspension).5mg/ml 5.mL Pediatric (6- yoa): 8.8 mg once daily Pediatric (3-7 yoa):.5 mg once daily Adults: 8.8 mg once daily Last Revision Date: April 08 Page
Adzenys XR-ODT (amphetamine ER dispersible) 3.mg Adzenys XR-ODT (amphetamine ER dispersible) 6.3mg Adzenys XR-ODT (amphetamine ER dispersible) 9.4 mg Adzenys XR-ODT (amphetamine ER dispersible).5mg Adzenys XR-ODT (amphetamine ER dispersible) 5.7mg Adzenys XR-ODT (amphetamine ER dispersible) 8.8mg extended release) 0mg extended release) 5mg extended release) 0mg extended release) 30mg extended release) 40mg extended release) 50mg extended release) 60mg Concerta (methylphenidate extended release) 8mg/ and nonequivalent methylphenidate extended release Concerta generic Concerta (methylphenidate extended release) 7mg/ and nonequivalent methylphenidate extended release Concerta generic Concerta (methylphenidate extended release) 36mg/ and nonequivalent methylphenidate extended release Concerta generic Concerta (methylphenidate extended release) 54mg/ and nonequivalent methylphenidate extended release Concerta generic Pediatric (6- yoa): 8.8 mg once daily Pediatric (3-7 yoa):.5 mg once daily Adults: 8.8 mg once daily ADHD (Pediatric and Adults): Doses greater than 60mg per day have not been studied and are not recommended Pediatric (6-yoa): 54mg per day have not been studied and are not recommended Pediatric (3-7yoa): 7mg per day have not been studied and are not recommended Adults (8-65yoa): 7mg per day have not been studied and are not recommended Daytrana (methylphenidate transdermal patch) 0mg/9hr Last Revision Date: April 08 Page 3
Daytrana (methylphenidate transdermal patch) 5mg/9hr Daytrana (methylphenidate transdermal patch) 0mg/9hr Daytrana (methylphenidate transdermal patch) 30mg/9hr 30mg/9hr were not studied Dextroamphetamine (DextroStat) 5mg Dextroamphetamine (DextroStat) 0mg Dexedrine (dextroamphetamine extended release) 5mg Dexedrine (dextroamphetamine extended release) 0mg Dexedrine (dextroamphetamine extended release) 5mg Dyanavel XR (amphetamine extended release).5mg per ml Narcolepsy: 5-60mg/day in divided doses 6 ADHD: 40mg/day 3 ADHD: Per FDA label, only in rare cases will it 4 be necessary to exceed a total of 40 mg per day. 4 8 ml ADHD: Per FDA label, daily doses above 0mg are not recommended. Focalin (dexmethylphenidate).5mg 3 Per FDA label, the Focalin (dexmethylphenidate) 5mg 3 maximum recommended Focalin (dexmethylphenidate) 0mg dose is 0mg/day (0mg twice daily). extended release) 5mg extended release) 0mg extended release) 5mg extended release) 0mg extended release) 5mg extended release) 30mg extended release) 35mg extended release) 40mg Intuniv (guanfacine extended release) mg Per FDA label, doses above 30mg/day in pediatrics and 40mg/day in adults have not been studied and are not recommended. Per the FDA label, doses above 4mg/day have not Last Revision Date: April 08 Page 4
Intuniv (guanfacine extended release) mg Intuniv (guanfacine extended release) 3mg Intuniv (guanfacine extended release) 4mg Kapvay (clonidine extended release) 0.mg extended release) 0mg extended release) 0mg extended release) 30mg extended release) 40mg extended release) 50mg extended release) 60mg Metadate ER (methylphenidate extended release) 0mg Metadate ER (methylphenidate extended release) 0mg Methylin Chew Tabs (methylphenidate).5mg Methylin Chew Tabs (methylphenidate) 5mg Methylin Chew Tabs (methylphenidate) 0mg Methylin Solution (methylphenidate) 5mg/5mL Methylin Solution (methylphenidate) 0mg/5mL Methylphenidate ER Osmotic Release 7mg been systematically studied in controlled clinical studies. 4 0.mg given twice daily Per FDA label, daily dosage above 60mg is not recommended. 3 Children 6yo: Per FDA label, daily dosage 3 above 60mg/day is not recommended 3 Children 6yo: Per FDA label, daily dosage 3 above 60mg/day is not recommended. 6 5 ml 30 ml Pediatric (3-7yoa): 7mg per day have not been studied and are not recommended Adults (8-65yoa): 7mg per day have not Last Revision Date: April 08 Page 5
been studied and are not recommended Mydayis.5 mg extened-release capsule (mixed salts of a single-entity amphetamine product) Mydayis 5 mg extened-release capsule (mixed salts of a single-entity amphetamine product) Mydayis 37.5 mg extened-release capsule (mixed salts of a single-entity amphetamine product) Mydayis 50 mg extened-release capsule (mixed salts of a single-entity amphetamine product) Procentra (dextroamphetamine) 5mg/5mL Quillichew ER (methylphenidate extended release) 0mg Quillichew ER (methylphenidate extended release) 30mg Quillichew ER (methylphenidate extended release) 40mg Adults: Doses above 50 mg daily have shown no additional clinically meaningful benefit Pediatric (3-7): Doses higher than 5 mg have not been evaluated in clinical trials in pediatric patients 60 ml ADHD: Per FDA label, only in rare cases will it be necessary to exceed a total of 40mg/day. Per the FDA label, daily dosage above 60 mg is not recommended. Quillivant XR (methylphenidate extended release) 5 mg/5 ml 60 mg or ml ADHD: Per FDA label, dosage >60mg/day is not recommended. Doses up to 60mg/day were studied in clinical trials. Ritalin (methylphenidate) 5mg 3 Children 6yo: Per FDA Ritalin (methylphenidate) 0mg 3 label, daily doses above Ritalin (methylphenidate) 0mg 3 60mg/day is not recommended. Ritalin LA (methylphenidate extended release) 0mg Ritalin LA (methylphenidate extended release) 0mg Per FDA label: daily dosage above 60mg is not recommended. Last Revision Date: April 08 Page 6
Ritalin LA (methylphenidate extended release) 30mg Ritalin LA (methylphenidate extended release) 40mg Ritalin LA (methylphenidate extended release) 60mg Ritalin SR (methylphenidate extended release) 0mg 3 Children 6yo: Per FDA label, daily doses above 60mg/day is not recommended. Strattera (atomoxetine) 0mg Strattera (atomoxetine) 8mg Strattera (atomoxetine) 5mg Strattera (atomoxetine) 40mg Children and adolescents: Doses of 0.5 to.8mg/kg/day were studied; Strattera (atomoxetine) 60mg.8mg/kg/day dose did Strattera (atomoxetine) 80mg not provide any Strattera (atomoxetine) 00mg additional benefit over that observed with the.mg/kg/day dose. Adults: Doses of 60 to 0mg/day were studied; mean final dose was approximately 95mg/day. capsule or chew 0mg capsule or chew 0mg capsule or chew 30mg capsule or chew 40mg capsule or chew 50mg capsule or chew 60mg capsule 70mg Per the FDA label, doses >70mg/day were not studied in clinical trials. Only once daily doses were studied. Zenzedi (dextroamphetamine).5mg Zenzedi (dextroamphetamine) 5mg 3 ADHD: Per FDA label, only in rare cases will it be necessary to exceed Zenzedi (dextroamphetamine) 7.5mg 8 a total of 40mg/day. Last Revision Date: April 08 Page 7
Zenzedi (dextroamphetamine) 0mg 6 Zenzedi (dextroamphetamine) 5mg Zenzedi (dextroamphetamine) 0mg 3 Zenzedi (dextroamphetamine) 30mg Last Revision Date: April 08 Page 8
Non-Discrimination and Accessibility Notice Discrimination is Against the Law Blue Cross and Blue Shield of North Carolina ( Blue Cross NC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross NC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross NC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages If you need these services, contact Customer Service -888-06-4697, TTY and TDD, call -800-44-708. If you believe that Blue Cross NC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Blue Cross NC, PO Box 9, Durham, NC 770, Attention: Civil Rights Coordinator- Privacy, Ethics & Corporate Policy Office, Telephone 99-765-663, Fax 99-87-563, TTY -888-9-783 civilrightscoordinator@bcbsnc.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator - Privacy, Ethics & Corporate Policy Office is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 00-800-368-09, 800- Last Revision Date: April 08 Page 9
537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. This Notice and/or attachments may have important information about your application or coverage through Blue Cross NC. Look for key dates. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Customer Service -888-06-4697. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call -888-06-4697 (TTY: -800-44-708). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al -888-06-4697 (TTY: -800-44-708). 注意 : 如果您講廣東話或普通話, 您可以免費獲得語言援助服務 請致電 -888-06- 4697 (TTY:-800-44-708) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số -888-06-4697 (TTY: -800-44-708). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. -888-06-4697 (TTY: - 800-44-708) 번으로전화해주십시오. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le -888-06-4697 (ATS : -800-44-708). ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم -888-06-4697. المبرقة الكاتبة: -800-44-708. LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau -888-06-4697 (TTY: -800-44-708). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните -888-06-4697 (телетайп: -800-44-708). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa -888-06-4697 (TTY: -800-44- 708). સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:સ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર -888-06-4697 (TTY: -800-44-708). ច ណ ប រស នបរ ប កអ នកន យ យជ ភ ស ខ ម រ បសវ កម ជ ន យខ នកភ ស ម ននតល ជ នសប ម រ ប កអ នកប យម នគ តថ ល ស ម ទ ន ក ទ នងត ម រយ បលម -888-06-4697 (TTY: -800-44-708) Last Revision Date: April 08 Page 0
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