CurrentCareSourcePolicy N/A

Arkansas Medicaid — Adult ADHD C-II Stimulant Prior Authorization Form and Instructions

This document is a prior authorization form and instructions for covering C-II stimulants and alternative ADHD medications for Arkansas Medicaid adult beneficiaries; it governs prescribers submitting PA requests to CareSource for Arkansas Medicaid members.

Policy Summary

PayerCareSource

PolicyAdult ADHD C-II Stimulant Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed PA form with required clinical documentation (diagnosis, DSM‑V symptoms, impairment details, comorbidities, substance‑use counseling if applicable) and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form to fax for pharmacy benefit

3alternative non-stimulant options listed

3major clinical sections on form

12+clinical question fields for ADHD assessment

Coverage Requirements for Adult ADHD Stimulants

Policy Summary

PayerCareSource

PolicyAdult ADHD C-II Stimulant Prior Authorization Form

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.

Diagnosis: Patient has a diagnosis of ADHD (or other approved diagnosis such as narcolepsy with confirmatory sleep study, traumatic brain injury, fatigue due to underlying illness, or Binge Eating Disorder for Vyvanse).

For narcolepsy include sleep study results on the initial request; Vyvanse is only for BED.

Documentation of impairment: For ADHD, document how and when ADHD was diagnosed and list the patient's specific DSM‑V ADHD symptoms (initial requests only); document clinically significant impairment in academic or occupational settings. If not in school or employed, provide medical necessity or limited treatment rationale (treatment limited to three months to aid in seeking employment).

If attending school or employed, specify setting (name of school or employer) and details (high school grade/college level or hours per semester).

Safety and comorbidity assessment: Document history and current status (treated/controlled or uncontrolled) of hypertension, schizophrenia, bipolar disease, heart disease, diabetes, anorexia/bulimia, substance or alcohol abuse, and provide additional information or justification when these conditions are present or uncontrolled.

If history of substance or alcohol abuse and patient currently receives counseling, fax written documentation including dates, times, type and location; if counseling occurred in the past, describe when and where. If patient continues to have symptoms of bipolar disease or schizophrenia or is non‑adherent to therapy, provide medical necessity for stimulant use.

Prescriber attestation: Prescriber signature certifying the accuracy of the Statement of Medical Necessity and supporting documentation is required.

Incomplete or illegible forms may delay processing or result in denial.

Provider Submission Requirements & Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for C-II stimulants when prescribed for adult ADHD. As alternatives, atomoxetine, clonidine IR, and guanfacine IR do not require prior authorization for treating adult ADHD. Incomplete or illegible forms may delay or result in denial of the prior authorization request.

Fax PA requests for pharmacy benefit to 1-866-930-0019 (Arkansas Medicaid).
Non-urgent and urgent request designations available; incomplete or illegible forms may delay processing or cause denial.

Step Therapy

Step Therapy / Non-Preferred Agent

Qelbree is a non-preferred agent and requires documentation of medical necessity. Providers must demonstrate failure of, intolerance to, or contraindication to atomoxetine and preferred C-II stimulants before approval of a non-preferred agent such as Qelbree.

Provide prior trial history and reason for discontinuation for atomoxetine and preferred C-II stimulants.
Document contraindications or clinically significant adverse effects if present.

Documentation Required

Required Clinical Documentation

Providers must supply detailed clinical information to support the PA request. For ADHD initial requests include diagnostic details, DSM‑V symptoms, behavioral therapies, and functional impact; for narcolepsy initial requests include sleep study results confirming the diagnosis.

Include ADHD diagnosis, how and when diagnosed, and specific DSM‑V symptoms (initial requests).
List current behavioral therapies and describe responses.
Document employment or school status and clinically significant impairment in those settings; if neither employed nor in school, provide medical necessity for C-II stimulant and note limits on treatment duration when applicable.
For narcolepsy initial requests: attach sleep study results confirming diagnosis.

Step Therapy

Non-Preferred Agent Documentation

When requesting a non-preferred agent (e.g., Qelbree), submit documentation of medical necessity that explains why atomoxetine and preferred C-II stimulants are not appropriate for this patient.

Attach prior treatment history demonstrating trial and failure, intolerance, or contraindication to atomoxetine and preferred C-II stimulants.
Provide clinical rationale for selecting the non-preferred agent over preferred alternatives.

Denial Risk

Form Completion

Incomplete or illegible forms may delay processing of the prior authorization request or result in denial. Ensure all required fields are completed and the prescriber signature and date are provided.

Fax legible, fully completed forms to 1-866-930-0019.
Include prescriber signature and date; unsigned requests may be denied.

Initial Therapy: Medical Necessity Criteria

Initial therapy rules

Initial PA must document diagnosis, impairment, and safety considerations.

Non-preferred agent trial: When requesting a non‑preferred agent (e.g., Qelbreee), provide documentation of medical necessity demonstrating failure or contraindication to atomoxetine and preferred C‑II stimulants prior to approval.

Qelbreee is non‑preferred and requires medical necessity documentation over atomoxetine and preferred C‑II stimulants.

Diagnosis and diagnostic details: Document whether the patient has ADHD; if yes, provide how and when ADHD was diagnosed in this adult patient and list current behavioral therapies.

On initial requests list the patient's specific DSM‑V ADHD symptoms (renewals skip this).

Functional impairment: Document whether the adult patient attends school or is employed and whether clinically significant impairment due to ADHD symptoms is present in the academic/school or occupational/work setting. Provide school/employer name and educational level or hours per semester when applicable.

If neither employed nor in school, provide medical necessity for a C‑II stimulant or note that treatment may be limited to three months to aid in seeking employment.

Safety screening and comorbidities: Address hypertension, schizophrenia, bipolar disease, heart disease, diabetes, anorexia/bulimia, substance or alcohol abuse and other relevant conditions; indicate treated/controlled status and provide additional information if selected.

If substance/alcohol abuse present, document counseling status and provide supporting documentation as required.

Attestation and completeness: Include prescriber signature certifying accuracy of the Statement of Medical Necessity and all supporting documentation; incomplete or illegible forms may delay processing.

Step	Requirement	Notes
1	Must try atomoxetine, clonidine IR, and guanfacine IR, or document a contraindication to these preferred alternatives, before a non-preferred agent (e.g., Qelbreee) will be approved.	Qelbreee is non-preferred and requires documentation of medical necessity over atomoxetine and preferred C-II stimulants.

Key Definitions and Clinical Terms

ADHD — documentation required (adult)

Required ADHD documentationDocument ADHD diagnosis with how and when diagnosed and list specific DSM-V ADHD symptoms for initial requests (skip symptom listing for renewals).

Functional impairment detailsIf attending school, state clinically significant impairment in the academic/school setting and provide school name and grade/college level (if college, list hours per semester).

Employment impairment detailsIf employed, state clinically significant impairment in the occupational/work setting and provide employer name; if not employed, explain reason and provide medical necessity for C-II stimulant.

Unemployed and seeking workIf neither employed nor in school but seeking employment, document impairment that impacts ability to seek employment; if not seeking employment, provide rationale for continued treatment (treatment limited to three months to aid in seeking employment).

Alternate diagnoses and evidenceFor diagnoses other than ADHD (eg, narcolepsy, TBI, fatigue due to illness, BED for Vyvanse), indicate diagnosis and, for narcolepsy, include sleep study results on initial request.

Medical necessity — C-II stimulant (adult)

Definition of medical necessity for C-II stimulantDocument clinically significant impairment in academic or occupational settings related to ADHD symptoms; if neither in school nor employed, provide justification (treatment limited to three months to aid in seeking employment).

Safety and comorbidity assessmentAddress presence and control status of hypertension, schizophrenia, bipolar disease, heart disease, diabetes, substance or alcohol abuse, anorexia/bulimia and explain or provide medical necessity if these are present or uncontrolled.

Substance abuse counseling documentationIf history of substance abuse and counseling provided, include documentation (dates/times/type/location) to support medical necessity and safe use of a C-II stimulant.

Prescriber attestationPrescriber must sign certifying accuracy of the Statement of Medical Necessity and supporting documentation to justify C-II stimulant use.

Background and Purpose

The prior authorization form is designed to gather diagnostic and functional-impact information to determine medical necessity for stimulant therapy in adults with ADHD. It requires documentation of the ADHD diagnosis (including DSM‑V symptoms and how/when diagnosed), evidence of clinically significant impairment in academic or occupational settings (or justification when not employed or in school), and assessment of comorbid conditions and safety considerations.

The form also requests details about prior and current treatments, behavioral therapies, substance use history and any counseling received, and a prescriber attestation certifying the accuracy of the Statement of Medical Necessity; incomplete or illegible forms may delay or result in denial of the request.

OpenPayer