CurrentAvMedPolicy N/A

Vyvanse (lisdexamfetamine) prior authorization for binge eating disorder

Form and clinical criteria governing prior authorization requests for Vyvanse prescribed for binge eating disorder (BED) for AvMed members; affects prescribers and supporting office staff submitting PA forms.

Policy Summary

PayerAvMed

PolicyVyvanse (lisdexamfetamine) prior authorization for binge eating disorder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must sign and print name on the PA request and submit the completed form with chart notes showing the member meets DSM BED criteria and is receiving psychotherapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 mg/dayrecommended dose

70 mg/daymaximum dose

>=1/wk x3mobinge frequency

3+associated features

chart notesdocumentation required

Coverage Criteria for Vyvanse (lisdexamfetamine) — Binge Eating Disorder

Clinical criteria for approval (BED)

Approval requires ALL of the following DSM-aligned criteria and documentation:

BED DSM criteria and documentation: 1) Patient eats an objectively large amount in a set time (Patient eats in a set amount of time an amount of food that is definitely larger than what most people would eat in that same amount of time) AND 2) Patient has a sense of lack of control over eating AND 3) Binge episodes are associated with 3 or more specified features (eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts when not physically hungry; eating alone because of embarrassment; feeling disgusted, guilty, or depressed afterward) AND 4) Patient has marked distress regarding the presence of binge eating AND 5) Patient's binge eating occurs on average at least once a week for 3 months AND 6) Chart notes documenting that the member meets all DSM criteria and is receiving psychotherapy from a behavioral health clinician must be submitted for approval.see text

All criteria must be met for approval per form.

The PA form includes a checkbox asking whether the patient is diagnosed with bulimia nervosa or anorexia nervosa. A positive response on that line conflicts with a binge eating disorder diagnosis and should be considered when evaluating the request; the form presents the question to document comorbid/alternative eating disorder diagnoses and does not by itself substitute for DSM-aligned chart documentation required for approval.

Policy Summary

PayerAvMed

PolicyVyvanse (lisdexamfetamine) prior authorization for binge eating disorder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must sign and print name on the PA request and submit the completed form with chart notes showing the member meets DSM BED criteria and is receiving psychotherapy.

SourceLink

On This Page

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Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Submission and Signature Required

Prior authorization submission and signature required — The prescribing physician must sign and clearly print their name (preprinted stamps not valid) on the completed prior authorization request. All other information may be completed by office staff. Fax the completed form and required documentation to 1-305-671-0200. If information (including phone and fax numbers) is incomplete, incorrect, or illegible, the authorization process can be delayed.

Fax: 1-305-671-0200
Prescriber signature required (no preprinted stamps)
Ensure phone and fax numbers are provided

Step Therapy

Samples and Non‑Formulary Initiation

Samples and non-formulary initiation — Use of medication samples to initiate therapy does not satisfy step-edit or preauthorization criteria. If the drug is non-formulary on the member's plan, documentation of medical necessity must be submitted with the prior authorization request.

Samples do not meet step-edit/preauthorization criteria
Non-formulary starts require medical necessity documentation

Documentation Required

Required Supporting Documentation

Required supporting documentation — Chart notes demonstrating that the member meets all DSM criteria for the diagnosis and documentation that the patient is currently receiving psychotherapy from a behavioral health clinician must be submitted for approval. All checked clinical criteria lines must be supported by documentation (e.g., chart notes, diagnostics, lab results) or the request may be denied.

Chart notes documenting DSM criteria required
Documentation of ongoing psychotherapy required
Provide height, weight, BMI, and number of binge eating days/week when applicable

Denial Risk

Incomplete or Insufficient Documentation

Incomplete or insufficient documentation — Authorization may be delayed or denied if the form is incomplete, incorrect, illegible, or if required supporting documentation (chart notes, psychotherapy documentation, medical necessity for non‑formulary drugs) is missing. Ensure all member and prescriber fields (including Member AvMed #, DOB, DEA or NPI, office contact, phone, fax) are completed to avoid delays.

Incomplete/illegible forms can delay or cause denial
Missing chart notes or psychotherapy documentation may result in denial
Include Member AvMed #, DOB, DEA or NPI, office contact, phone and fax

Background

Binge eating disorder (BED) is characterized by recurrent episodes of eating an objectively large amount of food in a discrete period with a sense of lack of control, associated distress, and specific accompanying features. The PA form aligns with DSM criteria by requiring documentation that binge episodes include 3 or more associated features (for example, eating rapidly, eating until uncomfortably full, eating alone due to embarrassment, or feeling disgusted/guilty afterward) and that episodes occur on average at least once per week for 3 months. Vyvanse (lisdexamfetamine) is indicated for moderate to severe BED and the form also notes dosing context: recommended dose 30 mg/day with a maximum of 70 mg/day; final approval requires submission of chart notes showing the member meets all DSM criteria and is receiving psychotherapy.

Definitions

inv-11: Definition — Binge eating episode

DefinitionAn episode in which the patient eats an amount of food that is definitely larger than what most people would eat in the same amount of time and experiences a sense of lack of control over eating

Form documentationPA form requires clinician to check that patient eats a definitely larger amount in a set time and endorses lack of control

Associated requirementsEpisodes must be associated with required features and marked distress per DSM criteria for approval

inv-12: Associated features of BED

Required associated features (select 3 or more)Eating much more rapidly than normal; Eating until feeling uncomfortably full; Eating large amounts when not physically hungry; Eating alone because of embarrassment; Feeling disgusted, guilty, or depressed afterward

Selection on formPA form lists these five features and requires 3 OR MORE to be checked for approval

Relation to approvalAssociated features are one of the DSM-aligned criteria that must be met and documented in chart notes

OpenPayer

Vyvanse (lisdexamfetamine) prior authorization for binge eating disorder

Coverage Criteria for Vyvanse (lisdexamfetamine) — Binge Eating Disorder

Diagnosis and Coding

Provider Actions and Submission Requirements

Background

Definitions

Initial Therapy Criteria and Dosing

Step Therapy and Sample Use