CurrentMass General Brigham Health PlanPolicy N/A

Attention Deficit Hyperactivity Disorder (ADHD) Stimulants

Defines pharmacy benefit step therapy, prior-authorization, and quantity limits for stimulant medications used to treat ADHD (and lisdexamfetamine for binge-eating disorder) for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Stimulants

Policy CodePolicy N/A

Change TypeMaterial updates (coverage, step therapy, quantity limits)

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit a prior authorization with documentation of prior trials or diagnosis when initial step-therapy requirements are not met.

SourceLink

POLICY UPDATE CHANGES

Added language allowing authorization for members new to the plan within the past 90 days who are currently receiving treatment.

Added generic Mydayis to the step therapy program and clarified that brand Vyvanse remains covered during shortage.

Updated approval criteria to allow approval for lisdexamfetamine capsule for the treatment of binge-eating disorder.

Added quantity limits to the Limitations section of the policy.

180 dayslookback for prior fills

90 daysnew-member continuity window

12 monthstypical approval duration

1/daycommon daily limit

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Coverage Criteria

Second-line approval criteria

Second-line medication approval will be granted when ONE of the following is met:

Second-line approval conditions: (a) Member has had a trial and failure, adverse reaction, or contraindication to at least two first-line long-acting stimulants>= 180 days

Also accepts prior fills within 180 days or continuity of care for members new to plan within 90 days as alternative approval path.

Second-line approval conditions: (b) Member has had a trial and failure with at least one second-line long-acting stimulant>= 180 days

Also accepts prior fills within 180 days or continuity of care for members new to plan within 90 days as alternative approval path.

Second-line approval conditions: (c) Request is for lisdexamfetamine capsule AND the member has a diagnosis of binge-eating disorder

Also accepts prior fills within 180 days or continuity of care for members new to plan within 90 days as alternative approval path.

New-member treatment continuity

Continuity of care exception

New-to-plan continuity: Member new to the plan within the past 90 days who is currently receiving treatment may be authorized (excluding products obtained only as samples or via manufacturer's patient assistance programs)90 days

Member must be currently receiving treatment; excludes samples and patient assistance program supplies.

Authorization excludes coverage when the product was obtained only as samples or through a manufacturer's patient assistance program (PAP). Such sources do not satisfy the documentation requirements for prior authorization or continuity-of-care exceptions.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prescriptions that meet the initial step therapy requirements will adjudicate automatically at the point of sale. If the prescription does not meet the initial step therapy requirements, the claim will deny with a message indicating that prior authorization (PA) is required. Providers should submit a PA request and include documentation supporting why the member does not meet initial step-therapy requirements.

Point-of-sale (POS) denial with PA requirement will occur when initial step-therapy criteria are not met.
Submit a PA request with required documentation (see documentation callout).

Step Therapy

Initial Step‑Therapy Requirements

First-line agents listed below are covered without prior authorization. Second-line agents will adjudicate only if the member has filled at least two different first-line long-acting stimulants or has filled a second-line medication within the past 180 days.

First-line (covered without PA): amphetamine/dextroamphetamine ER capsule (generic Adderall XR); methylphenidate extended‑release tablet (generic Concerta); dexmethylphenidate ER capsules (generic Focalin XR); methylphenidate CD capsules (generic Metadate CD); methylphenidate LA capsule (generic Ritalin LA).

Coding & Lookback

Prior fill lookback

Lookback period to satisfy second-line requirement>= 180 days

ContextSecond-line medications will pay if the member has filled at least two different first-line medications or a second-line medication within the past 180 days.

Alternative acceptancePrior fills within 180 days may be used to meet second-line criteria as documented in the policy.

Initial Therapy Criteria

First-line coverage

First-line agents covered without prior authorization

First-line list: Medications listed as first-line in the policy (e.g., amphetamine/dextroamphetamine ER capsule [generic Adderall XR]; methylphenidate ER tablet [generic Concerta]; dexmethylphenidate ER capsules [generic Focalin XR]; methylphenidate CD capsules [generic Metadate CD]; methylphenidate LA capsule [generic Ritalin LA]) are covered without prior authorization.

See policy for full product list.

Continuation Therapy Criteria

Continuation therapy

Continuity for members new to plan

Current treatment continuity: Members new to the plan within the past 90 days who are currently receiving treatment may be authorized without meeting step-therapy requirements90 days

Authorization excludes products obtained only as samples or via manufacturer's patient assistance programs.

Step Therapy Requirements

Requirement	Documentation needed
{"text":"Prior trials of first-line agents","status":""},{"text":"Evidence of trial and failure, adverse reaction, or contraindication to at least two first-line long-acting stimulants","status":""}
{"text":"Prior trial of second-line agent within lookback period","status":""},{"text":"Record of a fill for a second-line long-acting stimulant within the past 180 days" ,"status":""}
{"text":"Diagnosis-based exception for lisdexamfetamine","status":""},{"text":"Documentation of diagnosis of binge‑eating disorder when requesting lisdexamfetamine capsule","status":""}
{"text":"Continuity-of-care for members new to plan","status":""},{"text":"Evidence member is currently receiving treatment and has been on therapy within the past 90 days (excludes samples or manufacturer patient assistance programs)","status":""}

Per-Product Quantity Limits

Quantity limit

Drug and strengthAmphetamine/dextroamphetamine ER capsule (generic Adderall XR) 5, 10, 15 mg

Quantity limit1 capsule per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and strengthAmphetamine/dextroamphetamine ER capsule (generic Adderall XR) 20, 25, 30 mg

Quantity limit2 capsules per day

Approval duration

Background

This policy defines coverage and prior-authorization requirements for stimulant medications dispensed under the pharmacy benefit for attention‑deficit/hyperactivity disorder and related indications. It establishes a step‑therapy framework: a list of first-line long‑acting stimulants that are covered without prior authorization and criteria for approval of second-line agents. The policy also includes a continuity-of-care provision permitting authorization for members who are new to the plan within the past 90 days and are currently receiving treatment, while excluding products obtained only as samples or via patient assistance programs.

Definitions

First-line / Second-line definitions

Definition: First-line medicationsMedications listed as first-line are covered without prior authorization.

Definition: Second-line medicationsSecond-line medications require prior evidence of at least two different first-line medication fills or a second-line fill within the past 180 days to be paid.

Coverage implicationSecond-line agents require authorization unless member meets the step-therapy fill criteria or qualifies for continuity of care.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Stimulants

Policy CodePolicy N/A

Change TypeMaterial updates (coverage, step therapy, quantity limits)

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit a prior authorization with documentation of prior trials or diagnosis when initial step-therapy requirements are not met.

SourceLink

On This Page

Second-line (requires prior trials/fills or PA): Amphetamine/dextroamphetamine 3‑bead ER capsule (generic Mydayis); Methylphenidate transdermal patch (generic Daytrana); QuilliChew ER (methylphenidate hydrochloride) tablet; Quillivant XR suspension (methylphenidate hydrochloride); Dyanavel XR (amphetamine) oral suspension/tablet; Vyvanse (lisdexamfetamine) capsule / Lisdexamfetamine capsule.

Documentation Required

Required Documentation to Support Authorization

Documentation to support authorization must be submitted with the PA request. For members new to the plan within the past 90 days, authorization may be granted when the member is currently receiving treatment (excluding samples or manufacturer patient assistance program supplies) — include evidence of prior therapy, such as pharmacy fill history or provider records. If relying on trials or failures, include dates, medications tried, and reason for discontinuation (failure, adverse reaction, or contraindication).

Members new to the plan (<= 90 days): provide documentation showing active treatment (pharmacy records, clinical notes).
When requesting approval based on step-therapy exceptions: provide documentation of trials and failures (at least two different first‑line long‑acting stimulants OR at least one second‑line long‑acting stimulant), adverse reactions, or contraindications.
For lisdexamfetamine requests for binge‑eating disorder: include diagnosis documentation supporting the indication.

Denial Risk

Point‑of‑Sale Denial for Unmet Step Therapy

If the prescription does not meet initial step‑therapy rules at POS, the claim will deny and the adjudication message will instruct that PA is required. Providers should follow the PA submission instructions and attach the required documentation to avoid delays.

POS denial will display: prior authorization required for unmet step‑therapy.
After POS denial, submit PA with supporting documentation as specified above to request approval.

Approvals granted for 12 months

Quantity limit

DrugAmphetamine/dextroamphetamine 3-bead ER capsule (generic Mydayis)

Quantity limit1 capsule per day

Step-therapy statusListed as second-line in policy

Quantity limit

DrugDexmethylphenidate ER capsule (generic Focalin XR)

Quantity limit1 capsule per day

Step-therapy statusIncluded among first-line long-acting stimulants

Quantity limit

Drug and formulationDyanavel XR (amphetamine) suspension 2.5 mg/mL

Quantity limit8 mL per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and formulationDyanavel XR (amphetamine) tablet

Quantity limit1 tablet per day

Approval durationApprovals granted for 12 months

Quantity limit

DrugMethylphenidate ER transdermal patch (Daytrana)

Quantity limit1 patch per day

Step-therapy statusListed among second-line agents in policy

Quantity limit

DrugMethylphenidate LA capsule (Ritalin LA generic)

Quantity limit1 capsule per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and strengthsMethylphenidate ER tablet (Concerta generic) 18, 27, 54 mg

Quantity limit1 tablet per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and strengthMethylphenidate ER tablet (Concerta generic) 36 mg

Quantity limit2 tablets per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and formulationMethylphenidate ER CD capsule (Metadate CD generic)

Quantity limit1 capsule per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and strengthsQuillichew ER (methylphenidate) tablet 20, 40 mg

Quantity limit1 tablet per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and strengthQuillichew ER (methylphenidate) tablet 30 mg

Quantity limit2 tablets per day

Approval durationApprovals granted for 12 months

Quantity limit

Drug and formulationQuillivant XR (methylphenidate) oral suspension

Quantity limit12 mL per day

Approval durationApprovals granted for 12 months

Quantity limit

DrugLisdexamfetamine (Vyvanse) capsule

Quantity limit1 capsule per day

Indication noteAlso covered for binge-eating disorder when criteria are met