Prior Auth Protocol

FDA Approved Indications:

Health Net Approved Indications and Usage Guidelines:

AND

Failure or clinically significant adverse effects to two long acting (daily dosed) methylphenidate products (e.g., Concerta, Metadate CD, Quillivant XR, Ritalin LA, Daytrana)

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:

This field intentionally left blank.

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
Daytrana (methylphenidate transdermal patch)	Age 6-18: 10 mg patch applied transdermally QD two hours before needed effect and removed 9 hours after application	30 mg/day
Quillivant XR (methylphenidate oral suspension)	20 mg PO QD	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.