Under some plans, including plans that use an open or closed formulary, amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine CR, methamphetamine, Methylin, Methylin ER, methylphenidate, methylphenidate SR, Strattera, Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, Dexedrine CR, Dextrostat, Focalin, Focalin XR, Metadate CD, Metadate ER, Methylin, Ritalin, Ritalin LA, Ritalin SR and Vyvanse are subject to Precertification as specifically described below.   

According to the manufacturers, the stimulant agents can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below. A quantity of each drug will be considered medically necessary as indicated in the table below:

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit. Additional quantities of stimulant medications will be considered medically necessary for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets OR
• Member's dose is being titrated by physician (3-month limit) OR
• Member has had intolerance to drug administered as a single daily dose OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.

Adderall, Adderall XR, amphetamine/dextroamphetamine, Desoxyn, Dexedrine, Dexedrine CR, dextroamphetamine, dextroamphetamine CR, Dextrostat, methamphetamine and Vyvanse 

B.  Age limit for members greater than or equal to 65 years of age:
    
      A.  Member has tried and failed alternative drugs that are appropriate in the elderly    
            to treat the condition. OR
      B.  Member has been stabilized on the drug for an extended period and discontinuation or    
            change in the drug might result in physical and/or mental impairment.  OR
      C.  Member is in a critical or terminal state and disruption of therapy at this point would be
            inappropriate.  AND
            Member is being monitored.  AND
            Member has no known history of emergency department visits and/or hospital admissions
            from use of the drug in the member.

Under some plans, including plans that use an open or closed formulary, Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Focalin, Focalin XR, Metadate CD, Metadate ER 10mg, Methylin chew tabs/solution, Ritalin, Ritalin LA, Ritalin SR, Strattera and Vyvanse are subject to step-therapy.  Aetna considers these medications to be medically necessary for those members who meet the following step-therapy criterion:

For Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Focalin, Focalin XR, Metadate CD, Metadate ER 10mg, Methylin chew tabs/solution, Ritalin, Ritalin LA, Ritalin SR and Strattera

A documented trial of one month of one of the following covered alternatives: amphetamine/
dextroamphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine CR, Dextrostat, Metadate ER 20mg, methamphetamine, Methylin tablets, Methylin ER, methylphenidate or methylphenidate SR.

For Vyvanse

A documented trial of one month of the covered generic alternative dextroamphetamine CR.

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, or if the member meets transition of coverage (TOC) criteria for a medication subject to TOC, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section III below).

Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Focalin, Focalin XR, Metadate CD, Metadate ER 10mg, Methylin chew tabs/solution, Ritalin, Ritalin LA, Ritalin SR, Strattera and Vyvanse are currently Not Covered Part D drugs (Please Note: Desoxyn, Metadate ER and Strattera are covered drugs) under the Aetna Medicare Prescription Drug Plan*and are on the Aetna Step-Therapy List.*  Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step therapy criteria, unless a medical exception is granted.  Aetna considers these medications to be medically necessary for those members who meet the following criteria:

For Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Focalin, Focalin XR, Metadate CD, Metadate ER 10mg, Methylin chew tabs/solution, Ritalin, Ritalin LA, Ritalin SR and Strattera

A. A documented:

• Contraindication to one of the following covered alternatives: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine CR, Dextrostat, Metadate ER 20mg, methamphetamine, Methylin tablets, Methylin ER, methylphenidate or methylphenidate SR OR,
• Intolerance to one of the following covered alternatives: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine CR, Dextrostat, Metadate ER 20mg, methamphetamine, Methylin tablets, Methylin ER, methylphenidate or methylphenidate SR OR,
• Allergy to one of the following covered alternatives: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine CR, Dextrostat, Metadate ER 20mg, methamphetamine, Methylin tablets, Methylin ER, methylphenidate or methylphenidate SR OR,
• Failure of an adequate trial of one month of one of the following covered alternatives: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine CR, Dextrostat, Metadate ER 20mg, methamphetamine, Methylin tablets, Methylin ER, methylphenidate or methylphenidate SR OR,
• Member has a medical condition or a valid clinical reason that prevents the member from using a preferred oral alternative (Daytrana ONLY) OR
• Member has a documented diagnosis of anxiety, seizure disorder, Tourette's or a documented history or risk of drug abuse/rehabilitation (Strattera ONLY)

OR

B. Transition of Coverage: FOR Adderall XR, Concerta, Focalin, Focalin XR, Metadate CD or Ritalin LA - ONLY

• Member is within 90 days of his or her effective date of enrollment
• Member is stable on Adderall XR, Concerta, Focalin, Focalin XR, Metadate CD, or Ritalin LA for 30 days or longer
  
  If applicable, quantity limits, age or gender edits will apply.  Approval is valid one year from the date of request.
  
  If the member has been a Medicare member for 91 days or longer standard precertification, step-therapy, or medical exception criteria will apply.
   

For Vyvanse

A. A documented:

• Contraindication to the covered generic alternative dextroamphetamine CR OR,
• Intolerance to the covered generic alternative dextroamphetamine CR OR,
• Allergy to the covered generic alternative dextroamphetamine CR OR,
• Failure of an adequate trial of one month of the covered generic alternative dextroamphetamine CR

Dexedrine and Dexedrine CR are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step therapy criteria, unless a medical exception is granted.  Aetna considers these medications to be medically necessary for those members who meet the following criteria:

A.  A documented:

• Contraindication to one preferred alternative OR,
• Intolerance to one preferred  alternative OR,
• Allergy to one preferred alternative OR,
• Failure of an adequate trial of one month of one preferred alternative indicated for the member's condition.