CurrentCignaPolicy IP0584

Attention Deficit Hyperactivity Disorder (ADHD) Stimulants for Individual and Family Plans

Defines medical necessity, preferred-product step requirements, reauthorization, authorization durations, and exclusions for specified stimulant products (amphetamine and methylphenidate formulations) for Cigna individual and family plans.

Policy Summary

PayerCigna

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Stimulants for Individual and Family Plans

Policy CodePolicy IP0584

Change TypeAdded and revised product-specific criteria

Effective DateJul 1, 2025

Next Review Date

Key ActionProviders should obtain prior authorization when required by plan and document the qualifying diagnosis and prior trials/failures/contraindications/intolerances to the listed alternative products per product-specific criteria.

POLICY UPDATE CHANGES

Added criteria for dextroamphetamine immediate-release tablets, methylphenidate ER tablets (45mg, 63mg, 72mg), Relexxii, and Zenzedi.

Added criteria for Metadate CD.

For Metadate CD, methylphenidate extended-release 45mg/63mg/72mg tablets, and Relexxii: removed methylphenidate extended-release capsules (generic for Aptensio XR) from the list of alternatives in the preferred product criteria.

≥1Covered Indications (ADHD, binge-eating disorder for Vyvanse, narcolepsy, adjunctive depression, cancer-related fatigue, idiopathic hypersomnolence)

12 monthsInitial/Reauthorization Approval Duration

MultipleProduct-specific step/trial requirements

Not medically necessary conditions listed (examples)

Coverage Summary

Cigna defines medical necessity and preferred product sequencing for multiple amphetamine- and methylphenidate-containing stimulant products across their indicated diagnoses, including Attention Deficit Hyperactivity Disorder (ADHD), narcolepsy, binge-eating disorder, fatigue associated with cancer and/or its treatment, adjunctive/augmentation treatment for depression, and idiopathic hypersomnolence. This policy establishes product-specific step/trial requirements, reauthorization rules, and exclusions. Coverage stance: covered_with_criteria. Effective/Last review date: 07/01/2025.

Policy Metadata

Policy NumberIP0584

StatusCURRENT

Effective Date2025-07-01

Last Review2025-07-01

Typical Authorization Duration12 months

Initial Therapy Criteria

Medical Necessity Criteria (General)

Stimulant products are medically necessary when BOTH of the following are met:

ALL of the following

Documented diagnosis of ONE of the following: Attention Deficit Hyperactivity Disorder (ADD/ADHD); Binge-Eating Disorder in an Adult (18 years and older) [Vyvanse and lisdexamfetamine ONLY]; Narcolepsy; Adjunctive/Augmentation Treatment for Depression (must be age ≥18 and concurrently receiving other medication therapy for depression, e.g., SSRI); Fatigue Associated with Cancer and/or its Treatment; Idiopathic Hypersomnolence (diagnosis confirmed by a sleep specialist or a sleep disorders center).
Preferred Product Criteria is met (product-specific criteria in following nodes).

Product-specific Preferred Product Criteria

Criteria = Documentation of BOTH of the following:

ALL of the following

Continuation / Reauthorization Criteria

Reauthorization Criteria

Continuation is medically necessary when:

ALL of the following

Above medical necessity criteria continue to be met.
Documentation of beneficial response to therapy.

Billing Rule

Authorization Durations

Initial and reauthorization approvals are up to 12 months; prescribe and authorize accordingly.

Not Medically Necessary / Exclusions

Examples of uses considered not medically necessary (claims at risk for denial) include fatigue associated with Multiple Sclerosis (MS), long-term combination therapy (> 2 months) of atomoxetine (Strattera) with CNS stimulants, prescription use for neuroenhancement in otherwise healthy individuals, and use for weight loss. Providers should be aware that claims for these indications may be denied.

Denial Risk

Not Medically Necessary Uses

Claims for stimulant products for uses listed as not medically necessary are at risk for denial.

Fatigue associated with Multiple Sclerosis (MS)
Long-term combination therapy with atomoxetine (Strattera) and CNS stimulants (>2 months)
Neuroenhancement (use to augment cognition/affect in otherwise healthy individuals)
Weight loss (general use of stimulants for weight reduction)

Applicable Codes & Policy Identifiers

Policy Identifiersmixed

IP0584

Coverage Policy Number

Product-specific prior authorization requirements may apply (for example, Vyvanse criteria note 'may require prior authorization'); consult the applicable plan formulary for NDC-level coverage and obtain prior authorization when required by the plan.

Provider Actions

Prior Authorization

Prior Authorization Requirement May Apply

Certain product-specific criteria note 'may require prior authorization' (for example, Vyvanse when a patient cannot take the bioequivalent generic due to an inactive ingredient causing a significant allergy or serious adverse reaction). Providers should obtain prior authorization when required by the plan.

Vyvanse (lisdexamfetamine) may require prior authorization when the member cannot take the generic due to inactive ingredient allergy/serious adverse reaction

Documentation Required

Document Diagnosis and Trials

Providers must document the qualifying diagnosis and prior trials, failures, contraindications, or intolerances to the specific listed alternative products per the product-specific preferred product criteria.

Clinical Evidence & Guidelines

Evidence sources cited in this policy include the NCCN Cancer-Related Fatigue Guideline, which supports consideration of psychostimulants (e.g., methylphenidate) after other causes/strategies are evaluated, and the American Academy of Sleep Medicine (AASM) practice parameters (2007), which support use of amphetamine and methylphenidate for narcolepsy and possibly idiopathic hypersomnia.

Background

This policy addresses medical necessity and preferred product sequencing for multiple amphetamine- and methylphenidate-containing stimulant products. It references guideline and evidence sources for ADHD, narcolepsy and other hypersomnias, binge-eating disorder (Vyvanse), and cancer-related fatigue to inform coverage determinations and preferred product step requirements.

Definitions

FailureClinically inadequate response to a medication trial, intolerance, or contraindication as documented by provider.

Revision History

4/1/2024added

Added criteria for dextroamphetamine immediate-release tablets, methylphenidate ER tablets (45mg, 63mg, 72mg), Relexxii, and Zenzedi.

9/15/2024added

Added criteria for Metadate CD.

07/01/2025revisedLatest

Policy Summary

PayerCigna

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Stimulants for Individual and Family Plans

Policy CodePolicy IP0584

Change TypeAdded and revised product-specific criteria

Effective DateJul 1, 2025

Next Review Date

On This Page

Failure or intolerance to generic dextroamphetamine 5mg or 10mg OR Zenzedi 5mg or 10mg.

THREE of

amphetamine (generic for Evekeo) OR dextroamphetamine/amphetamine (generic for Adderall)
dexmethylphenidate (generic for Focalin)
methamphetamine (generic for Desoxyn)
methylphenidate chewable tablet OR methylphenidate tablet (generic for Ritalin) OR methylphenidate oral solution (generic for Methylin)

ALL of the following

Failure, contraindication, or intolerance to THREE of: dexmethylphenidate ER capsules (generic for Focalin XR); dextroamphetamine/amphetamine ER capsules (generic for Adderall XR); dextroamphetamine ER capsules (generic for Dexedrine); methylphenidate ER capsules (generics for Metadate CD or Ritalin LA).

ALL of the following

Failure, contraindication, or intolerance to THREE of: dexmethylphenidate ER capsules (generic for Focalin XR); dextroamphetamine/amphetamine ER capsules (generic for Adderall XR); dextroamphetamine ER capsules (generic for Dexedrine); methylphenidate ER capsules (generics for Metadate CD or Ritalin LA).

ALL of the following

Trial of methylphenidate extended-release capsule (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction.
Failure, contraindication, or intolerance to ALL of the following: dexmethylphenidate ER capsules (generic for Focalin XR); methylphenidate ER tablets (generic for Concerta); methylphenidate LA capsules (generic for Ritalin LA).

ALL of the following

Failure, contraindication, or intolerance to ALL of the following: dexmethylphenidate extended-release capsules (generic for Focalin XR); methylphenidate extended-release tablets (generic for Concerta); methylphenidate CD capsules (generic for Metadate CD) or methylphenidate LA capsules (generic for Ritalin LA).

ALL of the following

Age 13 years or older.
Failure, contraindication, or intolerance to ALL of the following: dexmethylphenidate ER capsules (generic for Focalin XR); dextroamphetamine/amphetamine ER capsules (generic for Adderall XR); dextroamphetamine ER capsules (generic for Dexedrine); methylphenidate ER capsules (generics for Metadate CD or Ritalin LA) OR methylphenidate ER tablets (generic for Concerta).

ALL of the following

Age 13 years or older.
Failure, contraindication, or intolerance to ALL of the following: dexmethylphenidate ER capsules (generic for Focalin XR); dextroamphetamine/amphetamine ER capsules (generic for Adderall XR); dextroamphetamine ER capsules (generic for Dexedrine); methylphenidate ER capsules (generics for Metadate CD or Ritalin LA) OR methylphenidate ER tablets (generic for Concerta).

ALL of the following

Failure, contraindication, or intolerance to ALL of the following: dexmethylphenidate extended-release capsules (generic for Focalin XR); methylphenidate extended-release tablets (generic for Concerta); methylphenidate CD capsules (generic for Metadate CD) or methylphenidate LA capsules (generic for Ritalin LA).

ALL of the following

Trial of lisdexamfetamine capsules (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction. [may require prior authorization]
THREE of
- dexmethylphenidate ER capsules (generic for Focalin XR)
- dextroamphetamine/amphetamine ER capsules (generic for Adderall XR)
- dextroamphetamine ER capsules (generic for Dexedrine)
- methylphenidate ER capsules (generics for Metadate CD or Ritalin LA) OR methylphenidate ER tablets (generic for Concerta)

ALL of the following

Trial of lisdexamfetamine chewable tablets (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction. [may require prior authorization]
THREE of
- dexmethylphenidate ER capsules (generic for Focalin XR)
- dextroamphetamine/amphetamine ER capsules (generic for Adderall XR)
- dextroamphetamine ER capsules (generic for Dexedrine)
- methylphenidate ER capsules (generics for Metadate CD or Ritalin LA)

ALL of the following

Failure or intolerance to dextroamphetamine 5mg or 10mg OR Zenzedi 5mg or 10mg.
THREE of
- amphetamine (generic for Evekeo) OR dextroamphetamine/amphetamine (generic for Adderall)
- dexmethylphenidate (generic for Focalin)
- methamphetamine (generic for Desoxyn)
- methylphenidate chewable tablet OR methylphenidate tablet (generic for Ritalin) OR methylphenidate oral solution (generic for Methylin)

Document the diagnosis (ADHD, narcolepsy, binge-eating disorder for Vyvanse, adjunctive depression, cancer-related fatigue, or idiopathic hypersomnolence)

Document trials/failures/intolerances/contraindications to the specific alternative products listed in product-specific criteria

Billing Rule

Authorization Durations

Initial and reauthorization approvals are up to 12 months; prescribe and authorize accordingly.

Denial Risk

Not Medically Necessary Uses

Claims for stimulant products for uses listed as not medically necessary are at risk for denial.

Fatigue associated with Multiple Sclerosis (MS)
Long-term combination therapy with atomoxetine (Strattera) and CNS stimulants (>2 months)
Neuroenhancement
Weight loss