ADHD Stimulants, Extended-Release (ER) (Adderall XR®, Adzenys ER™, Adzenys XR-ODT™, Aptensio XR™, Concerta®, Cotempla XR-ODT™, Daytrana®, Dexedrine Spansules®, Dyanavel XR®, Foaclin XR®, Metadate CD®, Methylphenidate 72mg ER tablets (branded product), Mydayis™, QuilliChew ER™, Quillivant XR®, Ritalin LA®, Ritalin SR®, Vyvanse® capsules and chewable tablets)

SELF ADMINISTRATION

Indications for Prior Authorization:
  • Attention Deficit Hyperactivity Disorder (ADHD)
The following agents are PREFERRED stimulants (prior authorization not required for any patients age 6 years or older):
  • amphetamine/dextroamphetamine ER capsules (generics to Adderall XR)
  • dexmethylphenidate ER capsules (generics to Focalin XR)
  • dextroamphetamine ER capsules (generics to Dexedrine Spansules)
  • methylphenidate ER capsules (generics to Metadate CD and Ritalin LA)
  • Metadate ER (generic)
  • methylphenidate SR tablets (generics to Ritalin SR)
  • methylphenidate ER tablets (generics to Concerta)
Patients must meet the following criteria for NON-PREFERRED stimulants:
  • Age 6 years or older, AND
  • Diagnosis of ADHD (for Vyvanse only: diagnosis of ADHD, OR adults with moderate to severe binge eating disorder), AND
  • Patient has tried and failed a preferred stimulant
    • Exceptions to trial and failure of a preferred stimulant:
      • Daytrana: if patient cannot swallow or has difficulty swallowing oral dosage forms
      • Vyvanse: for the treatment of adults with binge eating disorder

Last review date: July 10, 2019