CurrentAvMedPolicy N/A

Prior authorization and step-edit request for CNS stimulants (age 19+)

Form and criteria governing prior authorization and step therapy for adults (≥19 years) requesting CNS stimulant medications through AvMed; applies to prescribers and members when requesting listed stimulants.

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit request for CNS stimulants (age 19+)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateDec 30, 2025

Key ActionSubmit the completed PA form with diagnostic documentation (DSM-5 criteria, rating scales or psychological evaluation) and required attachments to AvMed; incomplete or missing information may delay or deny authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 x 30dRequired prior trials

Age 19+Population

MultipleProducts listed

Coverage and Initial Approval Criteria

Initial approval criteria

Covered when ALL of the following are met:

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Age: Patient is age 19 years or older>=19 years

population specified on form

Product listed: Requested CNS stimulant is one of the products enumerated on the PA form and the applicable box is checked on submissionN/A

must check drug box(es) on form

Diagnostic documentation: Written documentation substantiates a complete, appropriate, and covered diagnosis; prescribing history alone is insufficient. DSM-5 criteria must be used and impairment in more than one major setting documented; verification via a standardized rating scale, patient interview, or psychological evaluation must be submittedN/A

see checklist of verification methods on form

Specific diagnostic attachments: For narcolepsy: attach polysomnogram and MSLT results; for non‑FDA indications: attach chart notes and two peer‑reviewed clinical studies documenting safety and efficacyN/A

explicit attachment requirements listed on form

Step therapy for certain brands: If requesting specified Brand/ABA/AGA products (e.g., Adhansia XR, Adzenys, Aptensio XR, Azstarys, Cotempla XR ODT, Daytrana, Dyanavel XR, Evekeo/Evekeo ODT, Jornay PM, Mydayis, Quillichew ER, Quillivant XR, Xelstrym), member must have tried and failed 30 days each of three (3) generic stimulant medications, including at least one amphetamine‑based stimulant and one methylphenidate‑based stimulant, verified by chart notes and/or pharmacy paid claims3 trials x 30 days

applies when requesting the listed brand/ABA/AGA products

Use of manufacturer or office samples to initiate therapy does not satisfy the step-therapy or preauthorization requirements for CNS stimulants. Requests relying on sample use as evidence of prior trial or failure will not meet the criteria and additional documentation of an adequate, covered trial will be required for authorization.

Codes and Prior Trial Documentation

Diagnosis codes (requested on form)ICD-10

ICD-9/10

ICD code to be provided by prescriber for diagnosis (e.g., ADHD, narcolepsy, other)

Prior generic trials

RequirementMember must have tried and failed 30 days of therapy with three (3) generic stimulant medications; trials must include at least one amphetamine-based stimulant and one methylphenidate-based stimulant (verified by chart notes and/or pharmacy paid claims).

Duration per trial30 days

VerificationChart notes and/or pharmacy paid claims required to verify prior trials.

Applies whenRequesting Brand/ABA or generic/AGA for specified products (e.g., Adhansia XR, Adzenys, Aptensio XR, Azstarys, Cotempla XR ODT, Daytrana, Dyanavel XR, Evekeo/Evekeo ODT, Jornay PM, Mydayis, Quillichew ER, Quillivant XR, Xelstrym).

Prescriber Requirements and Submission Instructions

Prior Authorization

PA required for listed CNS stimulants

Prior authorization is required for listed CNS stimulant products for adults age 19 and above. Prescribers must submit complete documentation to support the requested drug and diagnosis. Incomplete, incorrect, or illegible information may delay or result in denial of authorization.

Fax completed form to 1-305-671-0200.
Do not use preprinted signature stamps — prescriber must hand-sign and print name on the request.
Ensure member and prescriber contact information (phone, fax, NPI) is complete on the form.

Step Therapy

Step therapy prior trials

When requesting certain brand or ABA/AGA products (Adhansia XR, Adzenys, Aptensio XR, Azstarys, Cotempla XR ODT, Daytrana, Dyanavel XR, Evekeo/Evekeo ODT, Jornay PM, Mydayis, Quillichew ER, Quillivant XR, Xelstrym), the member must have tried and failed three (3) generic stimulant medications, each for at least 30 days. The required trials must include at least one amphetamine-based stimulant and one methylphenidate-based stimulant. Trials must be verified by chart notes and/or pharmacy paid claims.

Amphetamine-based options include amphetamine/dextroamphetamine IR/ER, dextroamphetamine IR/SR, lisdexamfetamine (generic Vyvanse).
Methylphenidate-based options include dexmethylphenidate IR/ER and methylphenidate IR/ER formulations (e.g., Ritalin/Methylin, Ritalin SR/LA, Concerta, Metadate CD/ER).

Documentation Required

Diagnostic documentation required

Written documentation substantiating a complete, appropriate, and covered diagnosis is required for both new starts and members currently receiving any listed CNS stimulant; prescribing history alone will NOT meet criteria for approval. The diagnosis must be supported by DSM-5 criteria and documentation of impairment in more than one major setting when applicable.

If diagnosis was made by another prescriber, submit the diagnosing prescriber's name, date of diagnosis, copies of testing and chart notes detailing signs and symptoms.
If the DSM-5 was used, submit the patient-specific DSM symptoms, criteria, and any standardized rating scales or psychological evaluations used to make or verify the diagnosis (e.g., Adult Self-Report Scale v1.1, Wender Adult ADHD Rating Scale, member interview, psychological evaluation).

Documentation Required

Additional diagnostic/supporting documents

Attach additional supporting documents as applicable: for narcolepsy, submit polysomnogram and Multiple Sleep Latency Test (MSLT) results; for other or non‑FDA indications, submit chart notes, prior therapies tried, and two peer‑reviewed clinical studies demonstrating safety and efficacy for the requested off‑label indication. All submitted diagnostics, lab results, and chart notes that support each checked clinical criterion must be provided or the request may be denied.

Narcolepsy: attach polysomnogram and MSLT results.
Other/non‑FDA indications: attach chart notes, documentation of previous therapies tried, and two peer‑reviewed clinical studies for the indication.

Documentation Required

Form completion and signature

Prescriber signature (hand-signed — preprinted stamps not valid), printed prescriber name, prescriber NPI, and complete member/prescriber contact information (phone and fax) must be provided on the form. Office staff may complete other fields, but missing or incorrect contact details can delay processing.

Ensure the form includes: member AvMed number, date of birth, prescriber name, prescriber hand signature, signature date, office contact name, phone number, fax number, and NPI.
If information is incomplete or illegible, the authorization process can be delayed or denied.

Denial Risk

Missing drug or clinical details

Failure to check the applicable drug boxes or provide required clinical details (diagnosis, ICD code, dosing, weight if applicable, date weight obtained, and whether a previously prescribed CNS stimulant will be discontinued) may delay or result in denial of the authorization.

Be sure to check the box(es) for the requested drug(s) on the drug list.
Provide dosing schedule, length of therapy, diagnosis, ICD code, weight (if applicable) and the date weight was obtained.
Indicate if member will discontinue a previously prescribed CNS stimulant and list medications with effective dates.

Clinical Background

Attention‑deficit/hyperactivity disorder (ADHD) and narcolepsy are common indications for central nervous system stimulant therapy in adults and are explicitly listed on the AvMed PA form. To support stimulant therapy, the form requires documentation of diagnosis (with ICD code) and appropriate supporting attachments: for narcolepsy the polysomnogram and MSLT results must be submitted; for other/non‑FDA indications, attach chart notes and two peer‑reviewed clinical studies demonstrating safety and efficacy. The prescribing clinician must document that diagnostic standards (such as DSM‑5 criteria and relevant testing) and the clinical information requested on the form are present to meet prior authorization requirements.

Diagnostic and Definition Notes

Diagnostic confirmation

Diagnostic standardUse of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to determine that diagnostic criteria have been met, including documentation of impairment in more than one major setting.

Verification methodsDiagnosis must be verified using a standardized rating scale, patient interview, or psychological evaluation (examples listed on form: Adult Self-Report Scale V1.1; Member Interview; Wender Adult ADHD Rating Scale; Psychological Evaluation).

Required documentationPatient-specific DSM symptoms, criteria, psychological evaluation, and/or the standardized rating scale used to make or verify the diagnosis must be submitted with the form for approval.

ScopeApplies to ADHD diagnosis when requesting CNS stimulants for adults age 19 and above.

Initial Therapy Step Requirements

Initial therapy step requirements

Brand/ABA/AGA product requests require prior trials of generics:

Generic trial requirement: Member must have tried and failed 30 days of therapy with three (3) separate generic stimulant medications, including at least one amphetamine‑based stimulant and at least one methylphenidate‑based stimulant.3 trials x 30 days

Verification via chart notes and/or pharmacy paid claims required

Amphetamine‑based trial: At least one of the three trials must be an amphetamine‑based generic (examples listed on form include amphetamine‑dextroamphetamine IR/ER, dextroamphetamine IR/SR, lisdexamfetamine).>=1 amphetamine trial

form provides selectable amphetamine options

Methylphenidate‑based trial: At least one of the three trials must be a methylphenidate‑based generic (examples listed on form include dexmethylphenidate IR/ER, methylphenidate IR/ER and multiple generic formulations).>=1 methylphenidate trial

form provides selectable methylphenidate options

Required Step Trials

Step	Requirement
1	Member must have tried and failed 30 days of therapy with three (3) separate generic stimulant medications; the trials must include at least one amphetamine-based stimulant and at least one methylphenidate-based stimulant (verification by chart notes and/or pharmacy paid claims).

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit request for CNS stimulants (age 19+)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateDec 30, 2025

SourceLink

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