Prior authorization required (approvals up to 1 year)

Prior authorization is required for benefit coverage of ADHD stimulant medications; approvals for listed indications are provided for up to 1 year when criteria are met.

PA for branded/specialty ADHD stimulants unless exception met

Prior authorization is required for listed branded and specialty ADHD stimulant formulations unless the patient meets the swallowing‑impaired exception or satisfies the stepped‑therapy/prior‑trial pathway documented by the prescriber.

PA required for nonpreferred formulations with documented prior trials

Requests for branded or otherwise nonpreferred formulations require prior authorization and prescriber documentation of prior trials of the specified amphetamine or methylphenidate comparator products (bioequivalent generics or listed alternatives) per the product-specific criteria.

PA requires prior‑trial evidence of inadequate efficacy or intolerance

Prior authorization approvals require documentation that prior trials resulted in inadequate efficacy or significant intolerance (or that the patient cannot use the comparator) as attested by the prescriber.

Branded product trial expectations (bioequivalent generic and specific IR/ER trials)

For many branded products, prescribers must document trials of bioequivalent generics and trials of specific IR/ER methylphenidate or dexmethylphenidate products (or show inability to take the generic because of inactive‑ingredient differences) before branded product approval.

Step therapy: required trials of amphetamine ER and/or methylphenidate/dexmethylphenidate ER

Most branded/specialty stimulants require step therapy: prior trials of amphetamine mixed ER (generic for Adderall XR) and/or a dexmethylphenidate ER or methylphenidate ER product are required per product- and age‑specific rules.

Step therapy / required medication trials must be documented

Many branded products require documented trial and inadequate efficacy or intolerance to the specified generics (e.g., amphetamine mixed ER and a dexmethylphenidate or methylphenidate ER product) before approving the brand.

Required prior trials (failure or intolerance to listed alternatives)

Patients must have trialed and failed (or been intolerant to) the listed alternative stimulants (examples include dexmethylphenidate ER or methylphenidate ER and amphetamine IR/ER products) as detailed by product and age before approval for certain branded products.

Submit appropriate diagnosis/procedure codes or risk denial

When submitting claims or PA requests, providers must include appropriate diagnosis and procedure (billing) codes and use the most appropriate codes as of the submission date; claims not accompanied by covered codes will be denied as not covered.

Required documentation: age and prior stimulant therapy history

Prescriber documentation must state the patient’s age and a history of prior stimulant therapy including whether prior comparator products produced inadequate efficacy or significant intolerance, or evidence the patient cannot use comparator formulations.

Required supporting documentation: trial outcomes, allergies, swallowing issues

Supporting documentation should state which prior trials were attempted and whether there was inadequate efficacy or significant intolerance, and note allergies or inability to swallow when requesting ODT/chewable/liquid formulations.

Attestation of prior trials and outcomes required

Prescriber attestation is required that the patient tried and experienced inadequate efficacy OR significant intolerance with the specified prior stimulant products (products differ by age and therapy history) to meet prior‑trial criteria.

Claims without covered diagnosis/procedure codes will be denied

Claims or PA requests will be denied as not covered if submitted without covered diagnosis/procedure codes or if the request does not meet the policy criteria.

Denial triggers — unmet product criteria, prior‑trial or age mismatch

Requests may be denied if the patient does not meet the swallowing‑impaired pathway and also does not meet the stepped‑therapy/prior‑trial requirements for the specific product, including when required prior trials are not documented or age‑based criteria are unmet.

• Denial trigger when neither swallowing exception nor documented prior trials are present
• Denial trigger when age‑specific trial requirements are not met or documented

Conditions not covered — uses that will be denied

Stimulant products used for indications listed under 'Conditions Not Covered' (for example fatigue associated with MS, neuroenhancement, long‑term combination therapy with atomoxetine >2 months) are considered not medically necessary and may be denied.