CurrentcareoregonPolicy N/A

Lisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

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This document governs prior authorization requirements for generic lisdexamfetamine capsules (approval length: lifetime) for members covered by CareOregon; it specifies clinical criteria for ADHD and binge eating disorder and who may prescribe for BED.

Policy Summary

Payercareoregon

PolicyLisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document required trials, diagnosis, and for BED include binge episode frequency and a psychological treatment plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

LifetimeApproval length

2Indications

RequiredPrior trials

Coverage Criteria

Initial and Ongoing Coverage Criteria

Covered when ONE of the following sets of criteria is met

ADHD criteria: Diagnosis of ADHD AND trial and failure, contraindication, or intolerance to BOTH of the following: Generic Adderall XR OR dextroamphetamine ER; AND long-acting methylphenidate OR dexmethylphenidate.

Binge Eating Disorder criteria: Diagnosis of Binge Eating Disorder with documentation of at least 3 binge episodes per week; AND used in combination with a treatment plan that includes psychological treatment modalities (e.g., cognitive-behavioral therapy, interpersonal therapy); AND prescribed by a mental health provider; AND trial and failure, contraindication, or intolerance to BOTH SSRI and topiramate.>=3 binge episodes/week

No additional explicit exclusions are listed in this policy beyond the specific coverage criteria for generic lisdexamfetamine capsules described below. Coverage is governed by the indication-specific requirements for ADHD and Binge Eating Disorder; there are no other stated product exclusions in the document.

Policy Summary

Payercareoregon

PolicyLisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document required trials, diagnosis, and for BED include binge episode frequency and a psychological treatment plan.

SourceLink

On This Page

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CurrentcareoregonPolicy N/A

Lisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

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Sign up for all careoregon policy alerts

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Policy Summary

Payercareoregon

PolicyLisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document required trials, diagnosis, and for BED include binge episode frequency and a psychological treatment plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

LifetimeApproval length

2Indications

RequiredPrior trials

Coverage Criteria

Initial and Ongoing Coverage Criteria

Covered when ONE of the following sets of criteria is met

Policy Summary

Payercareoregon

PolicyLisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document required trials, diagnosis, and for BED include binge episode frequency and a psychological treatment plan.

SourceLink

On This Page

Initial therapy requirements

Initial authorization requires meeting one of the indication-specific criteria sets:

ADHD initial: Diagnosis of ADHD AND trial and failure, contraindication, or intolerance to BOTH: (1) Generic Adderall XR OR dextroamphetamine ER; AND (2) long-acting methylphenidate OR dexmethylphenidate.

BED initial: Diagnosis of Binge Eating Disorder with ≥3 binge episodes/week AND used with psychological treatment modalities AND prescribed by a mental health provider AND trial and failure, contraindication, or intolerance to BOTH SSRI and topiramate.>=3/week

Step	Required trials (trial and failure, contraindication, or intolerance)
{"text":"ADHD","status":""},{"text":"Must have trial and failure, contraindication, or intolerance to BOTH: Generic Adderall XR OR dextroamphetamine ER; AND long-acting methylphenidate OR dexmethylphenidate.","status":""}

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required; lifetime approval when criteria met

Prior authorization is required for generic lisdexamfetamine capsules. When criteria are met, approval length is lifetime.

Step Therapy

Step therapy: required prior trials or documented contraindication/intolerance

Require documented prior trials — or a documented contraindication or intolerance — to the specified stimulant and non‑stimulant agents before authorization is granted.

For ADHD: trial and failure, contraindication, or intolerance to BOTH: (1) Generic Adderall XR OR dextroamphetamine ER; AND (2) long-acting methylphenidate OR dexmethylphenidate.
For Binge Eating Disorder: trial and failure, contraindication, or intolerance to BOTH an SSRI AND topiramate.

Documentation Required

Required documentation to support diagnosis, trials, and BED treatment plan

Submit documentation that supports the diagnosis and required prior trials or their contraindication/intolerance; additional BED-specific documentation is required.

Diagnosis: ADHD OR Binge Eating Disorder (for BED include documentation of ≥3 binge episodes per week).
For BED: documentation that lisdexamfetamine will be used in combination with a treatment plan including psychological modalities (e.g., CBT, interpersonal therapy) and that the prescriber is a mental health provider.
Evidence of trials and failures, or documented contraindication/intolerance, to the required agents listed for the applicable indication.

Denial Risk

Denial triggers: missing trials or required documentation

Authorization may be denied if required trials or necessary documentation are not provided.

Missing documented trial and failure, contraindication, or intolerance to the required agents for the applicable indication (ADHD or BED).
For BED, missing documentation of ≥3 binge episodes/week, absence of a psychological treatment plan, or lack of a mental health prescriber.

Definitions

inv-08: Required prior trial — Trial and failure, contraindication, or intolerance

DefinitionTrial and failure, contraindication, or intolerance

Context for ADHDRequired prior trial means documented trial and failure, contraindication, or intolerance to BOTH: Generic Adderall XR OR dextroamphetamine ER; AND long-acting methylphenidate OR dexmethylphenidate.

Context for Binge Eating DisorderRequired prior trial means documented trial and failure, contraindication, or intolerance to BOTH an SSRI and topiramate as part of initial criteria for BED.

Background

Lisdexamfetamine is a central nervous system prodrug stimulant approved for treatment of attention‑deficit/hyperactivity disorder (ADHD) and for binge eating disorder (BED) in adults. Clinical use in this policy context follows trials of other stimulant or non‑stimulant therapies: for ADHD, a trial and failure (or contraindication/intolerance) to BOTH an amphetamine product (Generic Adderall XR OR dextroamphetamine ER) and a long‑acting methylphenidate product (or dexmethylphenidate) is required prior to approval. For BED, the policy requires documented ≥ 3 binge episodes per week, use in combination with a psychological treatment plan, prescription by a mental health provider, and trial and failure (or contraindication/intolerance) to BOTH an SSRI and topiramate.

Lisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

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Coverage Criteria

Lisdexamfetamine (generic lisdexamfetamine capsule) prior authorization

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Coverage Criteria

Initial Therapy Requirements

Step Therapy Requirements

Provider Actions & Prior Authorization

Definitions

Background

Quantity Limits