CurrentColorado Rocky Mountain Health PlansPolicy N/A

Stimulants and Strattera (< 6 years of age) prior authorization form

This form documents prior authorization requirements for prescribing stimulants or atomoxetine (Strattera) for patients younger than 6 years and specifies required clinical and administrative information that the prescriber must submit to Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyStimulants and Strattera (< 6 years of age) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete the form in full, include required medical records and recent labs, and fax to 1-866-940-7328 for prior authorization for patients under 6 years.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsmaximum length of approval

<6age group

5 yrsdocumentation retention

1-866-940-7328fax to submit

Coverage Criteria

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Information required for prior authorization review

Covered when ALL of the following information is provided on the form and supporting records:

Required submission items: Completed form with patient demographics, prescriber information, diagnosis (e.g., ADHD), target symptoms, comorbid diagnoses, prior behavioral interventions (with dates and reasons), previous medication therapy (name, dose, duration, reason for discontinuation), current medications, ability to swallow whole medications, vital signs (height, weight, BP, pulse), BMI%, cardiovascular disease history (patient or family), prescriber signature and date, and copies of medical records and recent related labs.Maximum length of approval = 6 months or less

Form must be completed in full; an incomplete form may be returned. Provider must retain documentation for five years and fax completed form to 1-866-940-7328.

No explicit clinical exclusion criteria are listed on this prior authorization form. The form focuses on collecting clinical and administrative information needed to establish medical necessity (diagnosis, target symptoms, comorbid diagnoses, prior behavioral interventions and medication trials, vital signs and growth measures, cardiovascular history, and supporting records) rather than enumerating conditions that would automatically exclude coverage.

The document does not specify any conditions that are explicitly considered "not medically necessary." Instead, it emphasizes that the form "must be completed in full" and warns that "an incomplete form may be returned." Failure to provide all required information and supporting records (diagnostic evaluations, recent chart notes, and related labs) may prevent review or approval.

Provider Actions and Submission Requirements

Prior Authorization

Prior authorization required for <6 years

Prior authorization is required for stimulants and Strattera when prescribed for patients under 6 years of age. Maximum approval length is 6 months or less.

Affected products: stimulants and Strattera for patients < 6 years.
Maximum approval length = 6 months or less.

Note

(Action Required) Complete and submit full form

Complete the prior authorization form fully and submit all required documentation. Incomplete submissions may be returned and will delay review or result in denial.

Form must be completed in full.
Fax completed form to 1-866-940-7328.

Documentation Required

Required documentation

Required documentation: All copies of medical records (diagnostic evaluations and recent chart notes) and the most recent related labs must be submitted. The provider must retain copies of all documentation for five years.

Include diagnostic evaluations and recent chart notes.
Include most recent related labs.
Provider must retain documentation for 5 years.

Denial Risk

Incomplete submission risk

Incomplete submissions may be returned; failure to provide the completed form and all required medical records, diagnostic evaluations, recent chart notes, and related labs will delay review and may result in denial.

An incomplete form may be returned.
Failure to provide all required records and labs risks denial or processing delays.

Background

This form is intended for children younger than six years who are being considered for stimulant medications or atomoxetine (Strattera). It captures key diagnostic and safety data to support a prior authorization request, including diagnosis (e.g., ADHD), target symptoms, comorbid medical and psychiatric diagnoses, prior behavioral interventions and prior medication trials (with dose, duration, and reasons for discontinuation), current medications, and whether the child can swallow medications whole. The form also requires vital signs and growth measures (height, weight, BMI%, blood pressure, pulse) and asks about a history of cardiovascular disease in the patient or family to assess safety. Providers must sign and date the form and submit all supporting medical records and the most recent related labs for review; the maximum length of approval is 6 months or less.

Treatment Modalities

Stimulant and Strattera prescribing

Medication-specific info: Form differentiates between high-dose stimulant, long-acting stimulant, and Strattera; requests drug name, dose, frequency, quantity, and duration of therapy requested.Maximum length of approval = 6 months or less

Applies to patients < 6 years of age; prior authorization is required.