CurrentAvMedPolicy N/A

Prior authorization and step-edit requirements for non-preferred CNS stimulants

This form and policy govern prior authorization and step-edit requirements for non-preferred central nervous system (CNS) stimulant medications for AvMed members; it applies to prescribing clinicians requesting coverage for listed non-preferred stimulant products.

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit requirements for non-preferred CNS stimulants

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and submit a completed prior authorization form with required prescriber signature and documentation proving three 30-day generic stimulant trials (including at least one amphetamine and one methylphenidate) via chart notes or pharmacy claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>15listed non-preferred CNS stimulant products

30drequired trial duration

3prior generic trials required

amphetamine+methylphenidaterequired classes in prior trials

Coverage Criteria

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Initial approval criteria

Covered when ALL of the following are met

Primary coverage criteria: 1) Provider submits completed prior authorization form with required prescriber signature and member/prescriber/drug details; 2) Written documentation substantiates a complete, appropriate, and covered diagnosis for new starts and current users; 3) Member has trialed and failed 30 days each of three (3) generic stimulant medications, including at least one amphetamine-based stimulant and one methylphenidate-based stimulant (verification via chart notes and/or pharmacy paid claims required); 4) For members >18 years, additional diagnostic criteria must be met using the 'CNS Stimulants for Adults Age 19 and Above' prior authorization form as referenced.

All documentation required or request may be denied

Coverage of a requested non-preferred central nervous system stimulant may vary by member Plan. If a drug is non-formulary on a Plan, documentation of medical necessity will be required. Providers should confirm member benefit details and include medical necessity justification when submitting the prior authorization request to avoid delays.

The policy explicitly states that use of samples to initiate therapy does not meet step edit/preauthorization criteria and will not satisfy prior therapy requirements. Prior therapy must be documented by chart notes or pharmacy paid claims showing the required trials and durations; samples alone are insufficient evidence of a completed trial.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — A written request with supporting documentation is required for all non‑preferred CNS stimulants. Prescribing history alone does not satisfy requirements; documentation must substantiate a complete, appropriate, and covered diagnosis for new starts and current users.

Fax completed form to 1-305-671-0200
Prescriber signature and printed name required (preprinted stamps not valid)

Step Therapy

Step Therapy Requirement

Step therapy required — Member must have trialed 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. Verification by chart notes and/or pharmacy paid claims is required.

Amphetamine-based examples: amphetamine‑dextroamphetamine IR/ER (generic Adderall), dextroamphetamine IR/SR, lisdexamfetamine (generic Vyvanse)
Methylphenidate-based examples: dexmethylphenidate IR/ER (generic Focalin), methylphenidate IR/ER (generic Ritalin, Concerta, Metadate)
Use of samples to initiate therapy does NOT meet step edit/prior authorization criteria

Documentation Required

Required Form Fields & Supporting Documentation

Required form fields and supporting documentation — Complete drug information and clinical documentation must be provided. Include prescriber signature (no preprinted stamps), member and prescriber contact information, drug name/form/strength, brand or generic indication, dosing schedule, length of therapy, diagnosis and ICD code, weight (if applicable) with date, and whether a previously prescribed CNS stimulant will be discontinued with effective dates. Attach chart notes, labs, and pharmacy claims as applicable.

Check the applicable drug(s) on the PA form — unchecked boxes will delay processing
Provide documentation to support each clinical criterion checked (chart notes, lab results, diagnostics, pharmacy paid claims)
If requesting a non‑formulary product, include medical necessity documentation

Denial Risk

Incomplete or Incorrect Requests May Delay or Deny Authorization

Incomplete requests may be delayed or denied — Incomplete, incorrect, or illegible information (including missing prescriber signature, missing drug details, or unchecked drug boxes) can delay the authorization process or result in denial.

Preprinted signature stamps are not valid
If form information is not complete, correct, and legible, additional processing time or denial may occur

Denial Risk

Insufficient Prior Therapy Documentation — Denial Risk

Insufficient prior therapy documentation risk — Failure to document required prior trials (classes and durations) or relying solely on samples/prescribing history may lead to denial. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Document 30‑day trials for three generic stimulants including both amphetamine‑ and methylphenidate‑based agents
Provide supporting pharmacy paid claims or chart notes to verify trials

Background

Central nervous system stimulants are prescribed for conditions such as attention-deficit/hyperactivity disorder and narcolepsy and include both amphetamine-based and methylphenidate-based agents. Because branded or formulation-variant stimulant products are non-preferred, the policy requires documentation to demonstrate medical necessity and prior therapeutic attempts on preferred generics. Specifically, the request must include diagnosis and supporting clinical documentation, and verification that the member has tried and failed the required generic stimulants (verified via chart notes and/or pharmacy paid claims). This documentation requirement ensures that non-preferred products are reserved for members who have not achieved adequate response or who have intolerance to appropriate, lower-cost alternatives.

Definitions / Examples

Amphetamine-based stimulants (examples listed)

Examples (amphetamine-based)amphetamine-dextroamphetamine IR/ER (generic Adderall/Adderall XR), dextroamphetamine IR/SR (generic Dextrostat/Procentra/Zenzedi/Dexedrine IR/ER), lisdexamfetamine (generic Vyvanse)

Formulations includedImmediate-release (IR) and extended-release (ER) formulations, oral solutions and ODT where listed (e.g., amphetamine ER ODT, Evekeo ODT)

Representative brand products listed in policyAdzenys ER Suspension; amphetamine ER ODT (Adzenys XR - ODT); amphetamine sulfate (Evekeo); Evekeo ODT; Xelstrym (dextroamphetamine)

Methylphenidate-based stimulants (examples listed)

Examples (methylphenidate-based)dexmethylphenidate IR/ER (generic Focalin/Focalin XR), methylphenidate IR/ER (generic Ritalin/Methylin/Ritalin SR/Ritalin LA/Concerta/Metadate CD/Metadate ER)

Formulations includedImmediate-release (IR) and extended-release (ER) formulations, transdermal patch (Daytrana), and liquid/extended-release suspensions where listed (e.g., Quillivant XR)

Representative brand products listed in policymethylphenidate ER (Aptensio XR), methylphenidate TD Patch (Daytrana), Quillivant XR, Quillichew ER

Requirement	Details
Number of required prior generic stimulant trials
Member must have tried and failed 3 generic stimulant medications (verification via chart notes and/or pharmacy paid claims)
Required stimulant classes included among trials
Trials must include at least one amphetamine-based stimulant and one methylphenidate-based stimulant
Minimum duration per trial
30 days of therapy for each generic stimulant trial
Documentation acceptable for verification
Chart notes and/or pharmacy paid claims; use of samples does not satisfy requirement

OpenPayer

Prior authorization and step-edit requirements for non-preferred CNS stimulants

Coverage Criteria

Coding & Prior Therapy Parameters

Provider Actions & Prior Authorization Requirements

Background

Definitions / Examples

Initial Therapy Criteria

Step Therapy Details