Subject: ADHD ST, Post PA (Aetna FI ACF Only) Policy 2937-D UDR 12-2023 v2

Drug

DEXEDRINE SPANSULE (BRAND ONLY)  (dextroamphetamine extended-release)

Policy:

FDA-APPROVED INDICATIONS
Dexedrine is indicated in:
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.


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 TWO of the following medications:
     –     Azstarys
     –     generic amphetamine/dextroamphetamine IR/ER (except generic for Mydayis)
     –     generic dexmethylphenidate IR/ER
     –     generic dextroamphetamine
     –     generic lisdexamfetamine
     –     generic methamphetamine
     –     generic methylphenidate IR/ER/SR (except generic for Relexxii 45 mg and 63 mg)
     –     generic atomoxetine
     –     generic clonidine extended-release (generic Kapvay)
     –     Qelbree
     –     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.


COVERAGE CRITERIA

Authorization may be granted for the requested drug when the following criteria is met:
     •   The patient has experienced an inadequate treatment response, intolerance, or has a
          contraindication to TWO of the following medications: Azstarys, generic
          amphetamine/dextroamphetamine (except generic for Mydayis), generic dexmethylphenidate,
          generic dextroamphetamine, generic lisdexamfetamine, generic methamphetamine, generic
          methylphenidate (except generic for Relexxii 45 mg and 63 mg), generic atomoxetine, generic
          clonidine extended-release (generic Kapvay), Qelbree, Zenzedi

DURATION OF APPROVAL (DOA)

          •  2937-D: DOA: 12 months

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Dexedrine Spansule [package insert]. Bridgewater, NJ: Amneal Pharmaceuticals LLC; October 2023.

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.

October 01, 2024