Subject: ADHD ST, Post PA (ACF FI Only) Policy 2937-D 11-2020

Drug

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) AGENTS

ADDERALL®  (amphetamine mixture immediate-release)

DEXEDRINE SPANSULE®  (dextroamphetamine extended-release)

DYANAVEL XR®  (amphetamine extended-release suspension)

FOCALIN XR®  (dexmethylphenidate extended-release)

PROCENTRA ®  (dextroamphetamine solution)

QUILLICHEW ER®  (methylphenidate extended-release)

QUILLIVANT XR®  (methylphenidate extended-release suspension)

Note: Type: Initial Step Therapy; Post Step Therapy Prior Authorization

Policy:

FDA-approved Indications           

Focalin XR, QuilliChew ER, Quillivant XR
These products are indicated for the treatment of Attention Deficit Hyperactivity Disorder (ADHD).

Dyanavel XR
This product is indicated for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in patients 6 years and older.

Adderall
These products are indicated for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) and Narcolepsy.

Dexedrine Spansule
Narcolepsy
Attention Deficit Disorder with Hyperactivity as an integral part of a total treatment program that typically includes other measures (psychological, educational, social) for patients (ages 6 years to 16 years) with this syndrome.

ProCentra
Narcolepsy
Attention Deficit Disorder with Hyperactivity as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in pediatric patients (ages 3 to 16 years) with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms: moderate to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity. 

INITIAL STEP THERAPY*
*Include Rx and OTC products unless otherwise stated.

If the patient has filled a prescription for at least a 14 day supply each of 3 of the following medications:

• generic amphetamine/dextroamphetamine IR/ER
• generic dexmethylphenidate IR/ER
• generic dextroamphetamine
• generic methamphetamine
• generic methylphenidate IR/ER/SR
• generic atomoxetine
• generic clonidine extended-release (generic Kapvay)
• Mydayis
• Vyvanse
• Zenzedi

within the past 180 days under a prescription benefit administered by CVS Caremark, then the requested drug will be paid under that prescription benefit. If the patient does not meet the initial step therapy criteria, then the claim will reject with a message indicating that a prior authorization (PA) is required. The prior authorization criteria would then be applied to requests submitted for evaluation to the PA unit

1. Precertification Criteria

The requested drug will be covered with prior authorization when the following criteria are met:

• The patient has experienced an inadequate treatment response, intolerance or contraindication to 3 of the following medications: A) generic amphetamine/dextroamphetamine, B) generic dexmethylphenidate, C) generic dextroamphetamine, D) generic methamphetamine, E) generic methylphenidate, F) generic atomoxetine, G) generic clonidine extended-release (generic Kapvay), H) Mydayis, I) Vyvanse, J) Zenzedi

Place of Service:

Outpatient

The above policy is based on the following references:

1. Adderall [package insert]. Parisppany, NJ: Teva Pharmaceuticals USA; March 2020.
2. Dexedrine Spansule [package insert]. Winchester, KY: Catalent Pharma Solutions; March 2019.
3. Dyanavel XR [package insert]. Monmouth Junction, NJ: Tris Pharma, Inc.; February 2019.
4. Focalin XR [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; November 2019.
5. ProCentra [package insert]. Newport, KY: Independence Pharmaceuticals, LLC; February 2017.
6. QuilliChew ER [package insert]. Monmouth Junction, NJ: Tris Pharma, Inc.; August 2018.
7. Quillivant XR [package insert]. Monmouth Junction, NJ: Tris Pharma, Inc.; October 2018.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

January 01, 2021