Asset Publisher
Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
Policy Number: PH-1179
This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
|
Effective Date |
Date of Origin |
|
10-01-2024 |
|
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|
|||||||||
|
|
Dextroamphetamine Sulfate Cap ER 24HR 5 MG |
5 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Chew Tab 10 MG |
10 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Chew Tab 2.5 MG |
2.5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Chew Tab 5 MG |
5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Tab ER 10 MG |
10 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Tab ER 20 MG |
20 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Tab ER 24HR 18 MG |
18 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Tab ER 24HR 27 MG |
27 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Tab ER 24HR 36 MG |
36 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Methylphenidate HCl Tab ER 24HR 54 MG |
54 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 10 MG |
10 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 12.5 MG |
12.5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 15 MG |
15 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 20 MG |
20 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 30 MG |
30 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 5 MG |
5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall |
Amphetamine-Dextroamphetamine Tab 7.5 MG |
7.5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adderall xr ; Mydayis |
amphetamine-dextroamphetamine ; amphetamine-dextroamphetamine cap er |
10 MG ; 12.5 MG ; 15 MG ; 20 MG ; 25 MG ; 30 MG ; 37.5 MG ; 5 MG ; 50 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 12.5 MG |
12.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 15.7 MG |
15.7 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 18.8 MG |
18.8 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 3.1 MG |
3.1 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 6.3 MG |
6.3 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 9.4 MG |
9.4 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Aptensio xr ; Jornay pm ; Ritalin la |
methylphenidate hcl cap delayed er ; methylphenidate hcl cap er |
10 MG ; 100 MG ; 15 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG ; 80 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Azstarys |
serdexmethylphenidate-dexmethylphenidate cap |
26.1-5.2 MG ; 39.2-7.8 MG ; 52.3-10.4 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 18 MG |
18 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 27 MG |
27 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 36 MG |
36 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 54 MG |
54 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Cotempla xr-odt |
Methylphenidate Tab Extended Release Disintegrating 17.3 MG |
17.3 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Cotempla xr-odt |
Methylphenidate Tab Extended Release Disintegrating 25.9 MG |
25.9 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Cotempla xr-odt |
Methylphenidate Tab Extended Release Disintegrating 8.6 MG |
8.6 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Daytrana |
methylphenidate td patch |
10 MG/9HR ; 15 MG/9HR ; 20 MG/9HR ; 30 MG/9HR |
30 |
Patches |
30 |
DAYS |
|
|
|
|
Desoxyn |
Methamphetamine HCl Tab 5 MG |
5 MG |
150 |
Tablets |
30 |
DAYS |
|
|
|
|
Dexedrine |
Dextroamphetamine Sulfate Cap ER 24HR 10 MG |
10 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
|
Dexedrine |
Dextroamphetamine Sulfate Cap ER 24HR 15 MG |
15 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
|
Dyanavel xr |
amphetamine chew tab extended release |
10 MG ; 15 MG ; 20 MG ; 5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Dyanavel xr |
Amphetamine Extended Release Susp 2.5 MG/ML |
2.5 MG/ML |
240 |
mLs |
30 |
DAYS |
|
|
|
|
Evekeo |
Amphetamine Sulfate Tab 10 MG |
10 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Evekeo |
Amphetamine Sulfate Tab 5 MG |
5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Evekeo odt |
amphetamine sulfate orally disintegrating tab |
10 MG ; 15 MG ; 20 MG ; 5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Focalin |
dexmethylphenidate hcl tab |
10 MG ; 2.5 MG ; 5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Focalin xr |
dexmethylphenidate hcl cap er |
10 MG ; 15 MG ; 20 MG ; 25 MG ; 30 MG ; 35 MG ; 40 MG ; 5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Intuniv |
guanfacine hcl tab er |
1 MG ; 2 MG ; 3 MG ; 4 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Kapvay |
Clonidine HCl Tab ER 12HR 0.1 MG |
0.1 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Metadate cd |
methylphenidate hcl cap er |
10 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Methylin |
Methylphenidate HCl Soln 10 MG/5ML |
10 MG/5ML |
900 |
mLs |
30 |
DAYS |
|
|
|
|
Methylin |
Methylphenidate HCl Soln 5 MG/5ML |
5 MG/5ML |
450 |
mLs |
30 |
DAYS |
|
|
|
|
Procentra |
Dextroamphetamine Sulfate Oral Solution 5 MG/5ML |
5 MG/5ML |
1800 |
mLs |
30 |
DAYS |
|
|
|
|
Qelbree |
Viloxazine HCl Cap ER |
100 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Qelbree |
Viloxazine HCl Cap ER |
150 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Qelbree |
Viloxazine HCl Cap ER |
200 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
|
Quillichew er |
Methylphenidate HCl Chew Tab Extended Release 20 MG |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Quillichew er |
Methylphenidate HCl Chew Tab Extended Release 30 MG |
30 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Quillichew er |
Methylphenidate HCl Chew Tab Extended Release 40 MG |
40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Quillivant xr |
Methylphenidate HCl For ER Susp 25 MG/5ML (5 MG/ML) |
25 MG/5ML |
360 |
mLs |
30 |
DAYS |
|
|
|
|
Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) |
45 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) |
63 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 72 MG |
72 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Ritalin |
methylphenidate hcl tab |
10 MG ; 20 MG ; 5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 10 MG (Base Equiv) |
10 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 100 MG (Base Equiv) |
100 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 18 MG (Base Equiv) |
18 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 25 MG (Base Equiv) |
25 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 40 MG (Base Equiv) |
40 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 60 MG (Base Equiv) |
60 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Strattera |
Atomoxetine HCl Cap 80 MG (Base Equiv) |
80 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Vyvanse |
lisdexamfetamine dimesylate cap |
10 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG ; 70 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Vyvanse |
lisdexamfetamine dimesylate chew tab |
10 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Xelstrym |
dextroamphetamine td patch |
13.5 MG/9HR ; 18 MG/9HR ; 4.5 MG/9HR ; 9 MG/9HR |
30 |
Patches |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 10 MG |
10 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 15 MG |
15 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 2.5 MG |
2.5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 20 MG |
20 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 30 MG |
30 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 5 MG |
5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Zenzedi |
Dextroamphetamine Sulfate Tab 7.5 MG |
7.5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
Dextroamphetamine Sulfate Cap ER 24HR 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Chew Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Chew Tab 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Chew Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Tab ER 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Tab ER 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Tab ER 24HR 18 MG |
18 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Tab ER 24HR 27 MG |
27 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Tab ER 24HR 36 MG |
36 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Methylphenidate HCl Tab ER 24HR 54 MG |
54 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 12.5 MG |
12.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall |
Amphetamine-Dextroamphetamine Tab 7.5 MG |
7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adderall xr ; Mydayis |
amphetamine-dextroamphetamine ; amphetamine-dextroamphetamine cap er |
10 MG ; 12.5 MG ; 15 MG ; 20 MG ; 25 MG ; 30 MG ; 37.5 MG ; 5 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 12.5 MG |
12.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 15.7 MG |
15.7 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 18.8 MG |
18.8 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 3.1 MG |
3.1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 6.3 MG |
6.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Adzenys xr-odt |
Amphetamine Tab Extended Release Disintegrating 9.4 MG |
9.4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Aptensio xr ; Jornay pm ; Ritalin la |
methylphenidate hcl cap delayed er ; methylphenidate hcl cap er |
10 MG ; 100 MG ; 15 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Azstarys |
serdexmethylphenidate-dexmethylphenidate cap |
26.1-5.2 MG ; 39.2-7.8 MG ; 52.3-10.4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 18 MG |
18 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 27 MG |
27 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 36 MG |
36 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Concerta ; Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 54 MG |
54 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Cotempla xr-odt |
Methylphenidate Tab Extended Release Disintegrating 17.3 MG |
17.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Cotempla xr-odt |
Methylphenidate Tab Extended Release Disintegrating 25.9 MG |
25.9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Cotempla xr-odt |
Methylphenidate Tab Extended Release Disintegrating 8.6 MG |
8.6 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Daytrana |
methylphenidate td patch |
10 MG/9HR ; 15 MG/9HR ; 20 MG/9HR ; 30 MG/9HR |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Desoxyn |
Methamphetamine HCl Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dexedrine |
Dextroamphetamine Sulfate Cap ER 24HR 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dexedrine |
Dextroamphetamine Sulfate Cap ER 24HR 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dyanavel xr |
amphetamine chew tab extended release |
10 MG ; 15 MG ; 20 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dyanavel xr |
Amphetamine Extended Release Susp 2.5 MG/ML |
2.5 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Evekeo |
Amphetamine Sulfate Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Evekeo |
Amphetamine Sulfate Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Evekeo odt |
amphetamine sulfate orally disintegrating tab |
10 MG ; 15 MG ; 20 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Focalin |
dexmethylphenidate hcl tab |
10 MG ; 2.5 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Focalin xr |
dexmethylphenidate hcl cap er |
10 MG ; 15 MG ; 20 MG ; 25 MG ; 30 MG ; 35 MG ; 40 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Intuniv |
guanfacine hcl tab er |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Kapvay |
Clonidine HCl Tab ER 12HR 0.1 MG |
0.1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Metadate cd |
methylphenidate hcl cap er |
10 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Methylin |
Methylphenidate HCl Soln 10 MG/5ML |
10 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Methylin |
Methylphenidate HCl Soln 5 MG/5ML |
5 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Procentra |
Dextroamphetamine Sulfate Oral Solution 5 MG/5ML |
5 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Qelbree |
Viloxazine HCl Cap ER |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Qelbree |
Viloxazine HCl Cap ER |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Qelbree |
Viloxazine HCl Cap ER |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Quillichew er |
Methylphenidate HCl Chew Tab Extended Release 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Quillichew er |
Methylphenidate HCl Chew Tab Extended Release 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Quillichew er |
Methylphenidate HCl Chew Tab Extended Release 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Quillivant xr |
Methylphenidate HCl For ER Susp 25 MG/5ML (5 MG/ML) |
25 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) |
63 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) |
45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Relexxii |
Methylphenidate HCl Tab ER Osmotic Release (OSM) 72 MG |
72 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Ritalin |
methylphenidate hcl tab |
10 MG ; 20 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 10 MG (Base Equiv) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 100 MG (Base Equiv) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 18 MG (Base Equiv) |
18 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 25 MG (Base Equiv) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 40 MG (Base Equiv) |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 60 MG (Base Equiv) |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Strattera |
Atomoxetine HCl Cap 80 MG (Base Equiv) |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Vyvanse |
lisdexamfetamine dimesylate cap |
10 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG ; 70 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Vyvanse |
lisdexamfetamine dimesylate chew tab |
10 MG ; 20 MG ; 30 MG ; 40 MG ; 50 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Xelstrym |
dextroamphetamine td patch |
13.5 MG/9HR ; 18 MG/9HR ; 4.5 MG/9HR ; 9 MG/9HR |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Zenzedi |
Dextroamphetamine Sulfate Tab 7.5 MG |
7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
|
QL Standalone |
Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ PS _ ADHD_ADD__QL _ProgSum_ 10-01-2024