Prior Auth Protocol

Prior Authorization Protocol

APTENSIO XR™ (methylphenidate hydrochloride extended-release)

HNMC

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- For the treatment of Attention Deficit/Hyperactivity Disorder (ADHD)
Health Net Approved Indications and Usage Guidelines:
- Diagnosis of attention deficit hyperactivity disorder
AND
- Failure or clinically significant adverse effects to two formulary alternatives (immediate release methylphenidate and extended release methylphenidate)
Coverage is Not Authorized For:
- Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
General Information:
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Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
methylphenidate extended release (Ritalin LA, Concerta, Metadate CD)	Ritalin LA: 20 mg Concerta: 18 - 36 mg PO QD Ritalin LA, Metadate CD: 20 mg PO QD	Concerta: 72 mg/day Ritalin LA, Metadate CD: 60 mg/day
methylphenidate immediate release (Ritalin)	Initial: 5 mg PO BID before breakfast and lunch; increase by 5 to 10 mg daily at weekly intervals	60 mg/day

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Aptensio XR	Patients 6 years and above: 10 mg PO QD Dose may be increased weekly in increments of 10 mg to a maximum of 60 mg/day. Capsules may be swallowed whole or opened and contents sprinkled onto applesauce.	Length of Benefit

Product Availability:

Extended-release capsules: 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg
References:

1. Aptensio XR [package insert]. Greenville, NC: Rhodes Pharmaceuticals: May 2015.
2. Micromedex^R DrugDEX, (online database). Truven Health Analytics, Greenwood Village, Colorado, USA. Accessed: October 10, 2015.

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.