ModifiedCignaPolicy IP0477

Attention Deficit Hyperactivity Disorder (ADHD) Stimulants for Employer Group Plans

Defines medical necessity and prior authorization criteria for stimulant products used to treat ADHD and related indications for employer group plans administered by Cigna (Complete Plan diagnostic criteria apply when prior authorization is required).

Policy Summary

PayerCigna

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Stimulants for Employer Group Plans

Policy CodePolicy IP0477

Change TypePreferred-product and formulary updates (multiple stimulantsgenerics added)

Effective DateN/A

Next Review DateN/A

Key ActionWhen prior authorization is required, document the diagnosis and trials/failure or intolerance to specified preferred alternatives per product-specific criteria.

SourceLink

POLICY UPDATE CHANGES

Updated the preferred product requirements for Vyvanse capsules to multi-source brand criteria and extended these criteria to the Standard, Performance and Legacy formularies.

Updated the preferred product requirements for Vyvanse chewable tablets to multi-source brand criteria and extended to the Standard, Performance and Legacy formularies.

Updated preferred product requirements for multiple stimulants including Adderall, Adderall XR, Adhansia XR, Adzenys XR-ODT, Aptensio XR, Concerta, Cotempla XR ODT, Desoxyn, Dexedrine, Dyanavel XR, Evekeo, and others.

Added amphetamine extended-release orally disintegrating tablets (generic for Adzenys XR-ODT) to the policy.

Updated the Adderall immediate-release tablets and Evekeo immediate-release tablets preferred product requirements.

~40stimulant products listed by name

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

~20distinct products with criteria

3formularies extended to

step therapystep therapy applies

02/15/2026most recent revision date

Medical Necessity and Product-Specific Criteria

Methylphenidate formulations (Metadate CD, Methylin, ER strengths) coverage

Standard/Performance/Value/Advantage/Total Savings/Legacy Drug List Plans:

ALL of the following

1. Documented diagnosis of ONE of the following: A. Attention Deficit Hyperactivity Disorder (ADD/ADHD) B. Narcolepsy C. Adjunctive/Augmentation Treatment for Depression and meets BOTH of the following: i. Individual is 18 years of age or older ii. Individual is concurrently receiving other medication therapy for depression (for example, selective serotonin reuptake inhibitors [SSRIs]) D. Fatigue Associated with Cancer and/or its Treatment E. Idiopathic Hypersomnolence and meets the following: i. Diagnosis is confirmed by a sleep specialist physician or at an institution (sleep center) that specializes in sleep disorders
ALL of the following
- 2. Individual meets the preferred covered alternatives criteria as indicated below:
- ALL of the following
  - Standard/Performance/Value/Advantage/Total Savings/Legacy Drug List Plans
    Documentation of BOTH of the following:
    A. Trial of methylphenidate immediate-release oral solution (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.
    B. Failure, contraindication, or intolerance to THREE of the following:
    i. amphetamine (generic for Evekeo) OR dextroamphetamine/amphetamine (generic for Adderall)
    ii. dexmethylphenidate (generic for Focalin)
    iii. dextroamphetamine sulfate (generic for Zenzedi) OR Procentra (dextroamphetamine solution)

Product and Procedure Coding

Listed stimulant products (no billing codes provided in this window)mixed

NDC/CPT not listed in this section

The document lists many brand and generic stimulant products (Adderall, Adderall XR, Adhansia XR, Adzenys XR-ODT, amphetamine IR/ER, Aptensio XR, Azstarys, Concerta, Cotempla XR-ODT, Daytrana, Desoxyn, Dexedrine, dexmethylphenidate products, Dyanavel XR, Evekeo, Focalin, Jornay PM, lisdexamfetamine, Metadate CD, Methylin, Mydayis, Procentra, QuilliChew ER, Quillivant XR, Relexxii, Ritalin variants, Vyvanse, Xelstrym, Zenzedi).

methylphenidate formulations (listed strengths)NDC

NDC (various)

methylphenidate formulations: 5 mg/5 mL and 10 mg/5 mL oral solution; 5 mg, 10 mg and 20 mg IR tablets; 2.5 mg, 5 mg and 10 mg chewable tablets; 10, 15, 20, 30, 40, 50 and 60 mg ER capsules; 10, 18, 20, 27, 36, 54 mg ER tablets.

Affected codes (referenced)mixed

affected codes

Codes referenced for prior authorization and coverage (document refers to affected codes but specific CPT/HCPCS/NDC codes appear elsewhere).

No procedure or billing codes in this sectionmixed

No codes listed

Number of required failed alternatives — examples

Typical required failuresPolicy examples require documented failure, contraindication, or intolerance to 3 or 4 preferred alternative agents depending on the product (examples: Desoxyn requires failure of three alternatives; several ER products require failure of four).

Product variationNumber required varies by product and Drug List (some products/plan lists specify failure of THREE agents; others specify FOUR).

Evidence of failure acceptedFailure, contraindication, or intolerance to listed alternatives is acceptable documentation per policy language.

Applies to branded/nonpreferredRequirement commonly applies to branded or nonpreferred stimulant products prior to coverage approval.

None

Prior Authorization, Documentation, and Step-Therapy Requirements

Note

Clinical considerations relevant to prior authorization

Prior authorization applies to the Complete Plan when noted; providers must document the clinical rationale and supporting records when requesting authorization. Clinical considerations that may inform prior authorization decisions include relevant guideline excerpts (e.g., AASM practice parameters for narcolepsy and hypersomnias, NCCN guidance on cancer-related fatigue, APA guidance on augmentation in MDD) and the need to rule out other causes of symptoms or attempt non-pharmacologic/alternate management strategies before stimulant therapy for certain indications.

Prior authorization diagnostic criteria apply to the Complete Plan only when prior authorization is required.
Guidelines note sleep specialist confirmation for idiopathic hypersomnolence/narcolepsy may be required.
For cancer-related fatigue, consider stimulants only after ruling out other causes and trying other management strategies.

Prior Authorization

Prior authorization impact

Policy and formulary updates (including changes to preferred-product requirements and addition of new generics or multi-source brand criteria) can change prior authorization, step-therapy sequencing, and coverage determinations. Providers should review the member's specific formulary and this coverage policy (including revision history) because preferred-product changes (for example, updates to Vyvanse/Adderall/Adzenys preferred requirements and addition of generic Adzenys XR-ODT) may alter required trials or cause prior authorization denials if required trials are not documented.

Policy Background and Scope

This policy supports medical necessity review for central nervous system stimulant medications used for Attention Deficit Hyperactivity Disorder (ADHD) and other indicated diagnoses including narcolepsy, adjunctive/augmentation treatment for depression (adults on concurrent antidepressant therapy), cancer-related fatigue, and idiopathic hypersomnolence. Some indications (for example idiopathic hypersomnolence) may require confirmation by a sleep specialist or specialized sleep center; product-specific criteria further define age limits, required trials of preferred alternatives, and formulation-specific exceptions.

Key Definitions and Abbreviations

Covered indications

Covered indications (summary)Documented diagnosis of ONE of: ADHD; Narcolepsy; Adjunctive/augmentation treatment for depression (adults concurrently receiving another antidepressant); Fatigue associated with cancer and/or its treatment; OR Idiopathic hypersomnolence (may require sleep specialist confirmation).

Adjunctive depression specificsFor adjunctive/augmentation treatment of depression, the individual must be ≥18 years and concurrently receiving other medication therapy for depression (e.g., SSRIs).

Age-related notesProduct-specific age limits apply for some products (e.g., many products ≥6 years; Mydayis ≥13 years).

Idiopathic Hypersomnolence confirmation

Specialist confirmation requiredDiagnosis of idiopathic hypersomnolence must be confirmed by a sleep specialist physician or at an institution (sleep center) that specializes in sleep disorders.

Care Setting Applicability

Outpatient

Outpatient level of care: Policy applies to outpatient prescribing of stimulant medications; no additional top‑level inpatient or other level‑of‑care nodes specified in this segment.

Chunk 35

Pharmacologic Augmentation and Adjunctive Use

Pharmacologic augmentation (stimulant adjunct)

Augmentation for depression: Stimulant augmentation may be considered as a pharmacologic adjunct for adults with suboptimally responsive major depressive disorder when used concomitantly with antidepressant therapy; evidence and duration guidance are limited and should be individualized.

Chunk 55

Pharmacologic augmentation (stimulants)

Stimulant augmentation contexts: Clinicians may use stimulants as adjunctive therapy for persistent depressive symptoms; documentation of concurrent antidepressant therapy is expected for coverage when indicated.

Chunk 55

Policy Summary

PayerCigna

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Stimulants for Employer Group Plans

Policy CodePolicy IP0477

Change TypePreferred-product and formulary updates (multiple stimulantsgenerics added)

Effective DateN/A

Next Review DateN/A

Key ActionWhen prior authorization is required, document the diagnosis and trials/failure or intolerance to specified preferred alternatives per product-specific criteria.

SourceLink

On This Page

iv. methamphetamine (generic for Desoxyn)

NoneNo code-specific thresholds or numeric values apply in this section.

Abbreviation contextThe 'None' entry is listed alongside dosage/formulation abbreviations (IR, ER, ODT) as a non-threshold value.

Usage noteUsed as a placeholder where no numerical threshold is defined for a code or product.

Preferred product requirement updates may change step-therapy sequences and prior authorization requirements.
Formulary-specific documents should be consulted for plan-specific preferred alternatives and exceptions.

Note

No explicit authorization/denial criteria in this segment

This policy segment provides clinical guidance and criteria but does not enumerate an exhaustive list of explicit authorization/denial operational rules; coverage decisions remain subject to plan language and clinical judgment by medical directors.

Absence of a specific operational authorization/denial checklist in this section — individual requests evaluated per criteria, documentation, and plan terms.

Documentation Required

Required documentation

Required documentation must support the documented diagnosis and any required trials, failures, contraindications, or intolerances to preferred alternatives. Acceptable documentation may include chart notes, laboratory tests, claims records, prescription history, and specialist consult notes. For certain diagnoses (e.g., idiopathic hypersomnolence), documentation from a sleep specialist or accredited sleep center confirming the diagnosis is required. For augmentation in depression, documentation of concurrent antidepressant therapy is required.

Chart notes, lab tests, claims history, and specialty consultation notes are acceptable forms of documentation.
Sleep specialist confirmation required for idiopathic hypersomnolence/narcolepsy where stated.
Concurrent medication therapy documentation required for adjunctive/augmentation indications (e.g., MDD).

Documentation Required

Allergy/intolerance to inactive ingredients

When a prescriber requests an exception based on allergy or intolerance to inactive ingredients (formulation differences), the prescriber must document that the formulation difference would result in a clinically significant allergic reaction or serious adverse event. Simple preference or tolerability without evidence of clinically significant reaction is insufficient.

Prescriber must document that inactive-ingredient differences would cause a significant allergy or serious adverse reaction to justify bypassing a bioequivalent generic or preferred product.

Note

No documentation checklist present in this section

There is no standardized documentation checklist included in this section. Providers should supply comprehensive supporting records (see 'Required documentation' callout) and consult plan-specific prior authorization forms or portals for any operational checklist requirements.

No formal documentation checklist present in this segment — follow guidance above and use plan-specific prior authorization forms where provided.

Step Therapy

Required trials / step therapy

Many branded/nonpreferred products require step-therapy: documented trials and failures (or contraindication/intolerance) of specified generic or preferred alternatives are required before coverage. The number and identity of required trial agents vary by product and formulary tier (examples below).

Required trials/failures are product- and formulary-specific (see individual product criteria).
Failure/contraindication/intolerance to a specified number of alternate agents is commonly required (ranges shown in product criteria: e.g., three or four alternatives for certain brands).

Step Therapy

Step therapy / preferred alternatives

Step-therapy usually requires trials of specific generic or preferred products (for example: dexmethylphenidate ER [generic Focalin XR], methylphenidate ER formulations [Concerta, Ritalin LA, Metadate CD], dextroamphetamine/amphetamine ER [Adderall XR/Mydayis], lisdexamfetamine [Vyvanse generics], or immediate-release amphetamine/dextroamphetamine products). Providers must document failure, contraindication, or intolerance to the exact alternatives listed for the member's formulary and drug tier.

Many branded stimulants list specific generics/preferred alternatives that must be trialed first (see product-specific criteria: Adderall XR, Adzenys XR-ODT, Desoxyn, Evekeo, Concerta, Ritalin LA, Vyvanse, etc.).
Failure to document required trials or inability to tolerate preferred alternatives may result in denial.

Note

No explicit step therapy rules stated in this segment

While many products have explicit step-therapy sequences, this segment does not prescribe universal procedural step-therapy rules applicable to all plans — some guidance suggests trying other management strategies or ruling out other causes (for example, for cancer-related fatigue) before medication. Always consult the specific product criteria and the member's formulary for the operative step-therapy sequence.

No single, explicit step-therapy rule applies across all products and formularies in this segment; product criteria must be followed individually.
Clinical judgment and plan-specific formulary rules determine step sequence and exceptions.

Potential denial risk

Absence of sleep specialist confirmation for idiopathic hypersomnolence may lead to denial of coverage.

Applies across productsSleep-specialist confirmation requirement is referenced in multiple product-specific criteria and general diagnostic nodes.

Formulation‑difference exemption

Exemption conditionPrescriber must document that the patient cannot take the bioequivalent generic due to a formulation difference in inactive ingredient(s) that would result in a significant allergy or serious adverse reaction.

Examples of differencesDifferences may include dyes, fillers, preservatives or other inactive ingredients per prescriber documentation.

Applies to initial therapy and formulation-specific requestsUsed when patients are new to stimulant therapy or when unable to swallow certain formulations and the bioequivalent generic is not tolerated due to inactive-ingredient differences.

Idiopathic hypersomnia — definition

Core featuresIdiopathic hypersomnia is characterized by constant or recurrent daytime sleepiness with no other cause of sleepiness, prolonged nocturnal sleep, difficulty awakening with sleep drunkenness, and long unrefreshing naps without history of cataplexy.

Relation to narcolepsyCondition is similar to narcolepsy but distinguished by absence of cataplexy and long unrefreshing naps.

Therapeutic contextStimulant medications may be used in management per practice parameters; specialist involvement is recommended for diagnosis.

Abbreviations

IRImmediate‑release

ERExtended‑release

ODTOrally disintegrating tablet

ADHDAttention‑deficit hyperactivity disorder

QD/BIDQD = once daily; BID = twice daily

Prescribing information (selected references)

MydayisMydayis extended‑release capsules prescribing information is referenced (see Mydayis PI).

Cotempla XR‑ODTCotempla XR‑ODT (methylphenidate ER ODT) prescribing information is cited in the references.

Adzenys ER / XR‑ODTAdzenys ER and Adzenys XR‑ODT prescribing information are referenced (product PIs cited).

Jornay PMJornay PM extended‑release capsules prescribing information is referenced in the bibliography.