Asset Publisher

ph-91179

print Print

Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary

Policy Number: PH-91179

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   

07-01-2024           

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

Adhansia xr ; Aptensio xr ; Jornay pm ; Ritalin la

methylphenidate hcl cap delayed er  ; methylphenidate hcl cap er

10 MG ; 100 MG ; 15 MG ; 20 MG ; 25 MG ; 30 MG ; 35 MG ; 40 MG ; 45 MG ; 50 MG ; 55 MG ; 60 MG ; 70 MG ; 80 MG ; 85 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

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

Adhansia xr ; Aptensio xr ; Jornay pm ; Ritalin la

methylphenidate hcl cap delayed er  ; methylphenidate hcl cap er

10 MG ; 100 MG ; 15 MG ; 20 MG ; 25 MG ; 30 MG ; 35 MG ; 40 MG ; 45 MG ; 50 MG ; 55 MG ; 60 MG ; 70 MG ; 80 MG ; 85 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

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

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

Qelbree

Viloxazine HCl Cap ER

100 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)

45 MG

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) 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:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication

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.

ALBP _  Commercial _ PS _ ADHD_ADD__QL _ProgSum_ 07-01-2024  _  © Copyright Prime Therapeutics LLC. May 2024 All Rights Reserved