State Health Plan: Central Nervous System (CNS) Stimulants Prior Authorization Program
Starting November 1, 2010, CNS stimulants - including generic and brand products - will require a coverage review for all claims for patients younger than age 5 and older than 18 years. These generic and brand products include: amphetamine/dextroamphetamine combinations (Adderall®, Adderall XR®); dexmethylphenidate (Focalin®, Focalin XR®); dextroamphetamine (Dexedrine®); lisdexamfetamine (Vyvanse®); methamphetamine (Desoxyn®); methylphenidate (Ritalin®, Methylin®, Methylin ER®, Ritalin SR®, Ritalin LA®, Metadate CD®, Metadate ER®, Concerta®); methylphenidate transdermal system (Daytrana®); atomoxetine (Strattera®); and guanfacine extended-release tablet (Intuniv®).
The State Health Plan is implementing this program to ensure appropriate utilization and to avoid the potential for misuse or abuse.
Coverage for CNS stimulants and Strattera will be provided immediately (without requiring a coverage review) for patients between the ages of 5 and 18 years, or for certain CNS stimulants if claim history includes medications used in the treatment of multiple sclerosis. Coverage for Intuniv, or all other claims not meeting the above criteria, will be determined through a prior authorization process.
Providers may call Medco toll-free at 1-800-417-1764, from 8 a.m. to 9 p.m., Eastern Time, Monday through Friday, to request a review. Members will be responsible for the full cost of the prescription if the provider does not receive approval during the coverage review.
Please visit the Plan website at www.shpnc.org for further information.