CurrentAnthemPolicy N/A

Prior Authorization Form — Stimulants/ADHD Medications (children under FDA age & adults >18)

A prior authorization form and requirements for stimulant and ADHD medication requests for Virginia Medicaid (Anthem HealthKeepers/HealthKeepers Plus) covering children younger than FDA-indicated ages and adults over 18. It specifies documentation and specialist prescriber requirements and questions to support non-preferred agent requests.

Policy Summary

PayerAnthem

PolicyPrior Authorization Form — Stimulants/ADHD Medications (children under FDA age & adults >18)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization form with required documentation (demographics, prescriber NPI, DSM-5 ADHD confirmation, substance use evaluation, medication details, and prior agent trials for non-preferred drugs).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 pagesform length

Virginiastate-specific

Adults >18PA applies to

Children <4specialist req

Coverage Criteria

Authorization Criteria

Covered when ALL of the following are met

Age and drug preference: If member is 4–17 years old and the stimulant is a preferred agent and member meets minimum FDA-approved age, prior authorization is not required; stimulants prescribed for children under age 4 must be prescribed by a pediatric psychiatrist, pediatric neurologist, or developmental/behavioral pediatrician, or in consultation with one of these specialists.age criteria

preferred agents for ages 4–17 exempt from PA; <4 requires specialist involvement

Adults over 18: Requests for stimulant/ADHD medications for adults over age 18 require completion of the form and supporting documentation to receive approval.age >18

applies to stimulants (non-stimulant agents excluded)

Policy Summary

PayerAnthem

PolicyPrior Authorization Form — Stimulants/ADHD Medications (children under FDA age & adults >18)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

DSM-5 diagnostic confirmation: Primary care clinician must have used the DSM-5 and determined criteria are met, including documentation of impairment in more than one major setting.DSM-5 criteria

required for approval

Substance use evaluation: Practitioner has regularly evaluated the member for stimulant or other substance use disorder and, if present, initiated treatment, consulted, or referred for evaluation/treatment.substance use assessment

required for maintenance requests

Non-preferred agent justification: For non-preferred stimulants/ADHD medications, the provider must list pharmaceutical agents attempted and the outcome and provide other pertinent information to support the requested agent.trial of prior agents

supports medical necessity for non-preferred drugs

This PA form does not apply to non-stimulant ADHD medications. Examples of non-stimulant agents excluded from this form include atomoxetine, clonidine ER, Kapvay®, guanfacine ER, Intuniv®, Qelbree®. Use the appropriate authorization pathway for those non-stimulant products rather than this stimulant-focused form.

Please include all requested information when submitting the completed form. Submission of documentation does NOT guarantee coverage, and incomplete or missing information may delay the prior authorization process or result in denial.

Coding & Diagnosis

ICD/diagnosis codesICD-10

No codes listed

Minimum FDA‑approved age for preferred stimulants

Minimum FDA‑approved age4 years — preferred stimulants/ADHD medications for individuals aged 4–17 who meet the minimum FDA‑approved age do not require prior authorization

PA exemption scopeApplies only to preferred stimulant agents for ages 4–17; member must meet the minimum FDA‑approved age

PA requirement for children <4Stimulants prescribed for children under age 4 require prescription by or consultation with a pediatric psychiatrist, pediatric neurologist, or developmental/behavioral pediatrician

Adults >18Requests for stimulants/ADHD medications for adults over age 18 require completion of the PA form

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required for certain stimulant/ADHD medication requests. PA is required for stimulants prescribed to children below the FDA‑approved minimum age and for adults over 18 requesting stimulants. Preferred stimulants for individuals ages 4–17 who meet the FDA‑approved minimum age do not require PA. Stimulants prescribed for children under age 4 must be prescribed by (or in consultation with) a pediatric psychiatrist, pediatric neurologist, or developmental/behavioral pediatrician.

Preferred stimulants/ADHD medications for individuals 4–17 years old who meet the FDA minimum age: no PA required
PA required for stimulants prescribed to children below FDA‑indicated age and for adults >18 (stimulants only; non‑stimulant ADHD agents may follow different rules)
Stimulants for children <4 must be prescribed by or in consultation with a pediatric psychiatrist, pediatric neurologist, or developmental/behavioral pediatrician

Step Therapy

Non‑preferred Agent Trial Documentation

For requests involving non‑preferred stimulant/ADHD medications, document prior trials and outcomes. Provide the names of previously tried agents, approximate dates or durations of trials, and the reason each agent was discontinued or considered ineffective/intolerable.

List pharmaceutical agents attempted and outcome (include drug name, dates/duration, and reason for discontinuation or failure)
Provide supporting clinical rationale why the non‑preferred agent is needed for this member

Documentation Required

Required Documentation and Clinical Information

Submit complete clinical and administrative information with the PA request. Incomplete submissions may delay or prevent approval. The following member and clinical data should be included: member demographics and Medicaid ID, date of birth, current weight (kg); prescriber name and contact details including NPI; drug name, strength, dosing frequency, quantity, and length of therapy; ICD diagnosis code(s); documentation that DSM‑5 diagnostic criteria were used when applicable (including impairment in >1 major setting); for maintenance requests, documentation of regular evaluation for stimulant or other substance use disorder and any treatment/consultation/referral; and for children <4, documentation of specialist prescriber or consultation.

Member: full name, Medicaid ID, date of birth, weight in kilograms
Prescriber: name, NPI number, phone and fax
Drug details: name, formulation, strength, dosing frequency, quantity per day, length of therapy
Diagnosis: ICD code(s) and documentation of DSM‑5 diagnostic criteria (if applicable) including evidence of impairment in >1 setting
Maintenance requests: documentation of evaluation for stimulant/substance use disorder and any treatment, consultation, or referral
Non‑preferred agents: list prior agents tried and outcomes (see above)
Children <4: documentation that prescriber is a qualifying pediatric specialist or that consultation with one occurred

Denial Risk

Incomplete Submission May Delay or Prevent Approval

Incomplete or illegible submissions will delay the PA process and may prevent approval. Submission of required documentation does not guarantee coverage. Include all requested information and the prescriber signature. Fax the completed form and supporting documentation to 844‑512‑7020.

Incomplete forms or missing information may delay or prevent PA approval
Submission of documentation does NOT guarantee coverage
Prescriber signature required to attest information accuracy
Fax completed form to 844-512-7020

Background

This prior authorization form supports clinical review of stimulant and ADHD medication requests when use is outside routine preferred parameters — for example, stimulant prescriptions for adults over age 18 or for children below preferred age ranges. The form requires documentation that the prescriber has applied DSM-5 diagnostic criteria with evidence of impairment in more than one major setting, lists the diagnoses treated (including ICD codes), and clarifies whether the request is for a non-preferred stimulant that requires justification of prior trials and outcomes.

Definitions

DSM‑5 diagnostic criteria and documentation

DSM‑5 diagnostic usePrimary care clinician must have used the DSM‑5 to determine ADHD diagnostic criteria were met

Documented impairment requirementDocumentation must show impairment in more than one major setting

ICD codingInclude all relevant ICD diagnosis codes for the conditions being treated on the form

ApplicabilityThis DSM‑5 confirmation requirement is part of the approval process for stimulants/ADHD medications for adults over 18 (per form instructions)

Initial Therapy Requirements

Initial prescriptions for stimulants when outside usual age ranges require prior authorization and specific documentation.

Specialist prescriber for children <4: Stimulants for children under age 4 must be prescribed by a pediatric psychiatrist, pediatric neurologist, or developmental/behavioral pediatrician, or in consultation with one of these specialists.

Maintenance Therapy / Continuation Criteria

Maintenance Therapy

Maintenance requests must include ongoing evaluation for substance use disorders and confirmation of continued need.

Maintenance substance use monitoring: The practitioner has regularly evaluated the member for stimulant or other substance use disorder and, if present, initiated specific treatment, consulted with an appropriate health care provider, or referred the member for evaluation/treatment.

Step Therapy / Prior Agent Trials

Prior agent tried (name & formulation)	Dates tried (approx.)	Outcome (reason for discontinuation or response)
Provide each non-preferred stimulant or ADHD medication previously trialed (include formulation and strength)
Approximate dates or duration of each trial (mm/yyyy – mm/yyyy or duration in weeks/months)
Document outcome: e.g., inadequate response, adverse effects (specify), intolerance, partial response, or clinical improvement