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Limited coverage drugs – atomoxetine

Last updated on August 7, 2024

Generic name

 atomoxetine

Strength

10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

Form

capsule

Special Authority criteria

 Approval period

For patients 6 years of age and older diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) with hyperactivity, impulsivity, or inattention that interfere with functioning

PLUS

  • Patient has been previously tried on both methylphenidate
    AND an amphetamine with unsatisfactory results or intolerance*

OR

  • Patient has contraindication(s) to stimulants

* See Special Notes below

Indefinite

Practitioner exemptions

  • None

Special notes

  • Unsatisfactory trial of or intolerance to both methylphenidate AND an amphetamine: defined as no demonstrated effectiveness for symptoms of ADHD or functional impairment secondary to ADHD after a minimum 1-week trial of an adequate dose of both methylphenidate AND an amphetamine. At least one trial must be with an extended-release/long-acting stimulant. Specific details of drug, dose and duration tried, and unsatisfactory response are required, as applicable
  • Specific details of medication intolerance or contraindication must be included in the Special Authority Request
  • Coverage is not intended for "performance enhancement" in patients who do not have symptoms or functional impairment
  • Criteria applicable to all plans including Plan G

Special Authority request form(s)