CurrentMass General Brigham Health PlanPolicy N/A

Attention Deficit Hyperactivity Disorder (ADHD) — Pharmacy Step Therapy and Prior Authorization

Mass General Brigham Health Plan policy describing pharmacy benefit coverage, step-therapy, prior authorization, and quantity limits for Attention Deficit Hyperactivity Disorder (ADHD) medications; applies to plan providers and pharmacists dispensing covered members' prescriptions.

Policy Summary

PayerMass General Brigham Health Plan

PolicyADHD medication coverage — step therapy and PA

Policy CodePolicy N/A

Change TypeAdded indication

Effective DateApr 17, 2019

Next Review DateN/A

Key ActionIf a prescription does not meet step-therapy at point of sale, submit a prior authorization with documentation of diagnosis and trials of two preferred long-acting products.

SourceLink

POLICY UPDATE CHANGES

Narcolepsy diagnosis was added as an indication for coverage.

12 monthsPA duration

30/moDaytrana limit

30/moVyvanse limit

2Required trials

Coverage and Step-Therapy Requirements

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inv-02: First-Line Medication Coverage

First-line medications are covered without prior authorization when prescribed.

First-Line coverage: Medications listed as first-line are covered without prior authorization at point of sale

See list of first-line products in chunk 4

inv-01: Second-Line Medication Approval Criteria

Coverage for ADHD medications is tiered by first-line and second-line status; second-line agents require meeting specific clinical criteria.

Second-Line agent approval general: Approval of a second-line medication will be granted if the member meets ALL of the following:

Diagnosis requirement: Member has a diagnosis of ADD/ADHD (required for Daytrana, QuilliChew ER, Quillivant XR, Dyanavel XR, Vyvanse) OR for Vyvanse an alternative indication of binge eating disorder; narcolepsy is listed as an indication for Daytrana, QuilliChew ER, and Quillivant XR

Supported in chunks 5-7

Trial requirement: Member has tried and had a documented side effect, allergy, or treatment failure from two (2) preferred, long-acting (once-a-day) products2 failed preferred long-acting products

Applies to Daytrana, QuilliChew ER, Quillivant XR, Dyanavel XR, Vyvanse per chunks 5-7

This policy applies to pharmacy benefit coverage of medications for Attention Deficit Hyperactivity Disorder (ADHD). First-line products listed in the policy are covered at the point of sale without prior authorization. Second-line products (see policy product list) are subject to the plan's step-therapy requirements and will only pay without additional review when those requirements are met.

Program-type restrictions such as specialty-tier limitations are not specified in this policy; therefore, specialty limitations are noted as N/A in the context of these coverage criteria. If a prescription does not meet the initial step-therapy requirements at point of sale, it will deny and require submission of a prior authorization request.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-first-line ADHD medications. If a prescription is for a second-line agent (see criteria below) and the member does not meet the initial step-therapy requirements, submit a prior authorization (PA) request for coverage consideration.

Applies to second-line ADHD medications (e.g., Daytrana, QuilliChew ER, Quillivant XR, Dyanavel XR, Vyvanse)

Denial Risk

Point-of-Sale Denial for Unmet Step Therapy

Prescriptions that do not meet the initial step-therapy requirements will deny at the point of sale with a message indicating that prior authorization is required. If a claim denies at POS for unmet step therapy, submit a PA with the required documentation to avoid delay.

Documentation Required

Required Documentation for Second-Line Agents

When requesting PA for second-line agents, include documentation of the member's diagnosis and prior medication trials or intolerances as specified below. Adequate documentation includes diagnoses (e.g., ADD/ADHD, narcolepsy, binge eating disorder where applicable), dates of fills, and clinical notes showing treatment failure, intolerance, or allergy to preferred agents.

Include diagnosis (ADD/ADHD, narcolepsy, or binge eating disorder when applicable)
Document trials of preferred first-line, long-acting (once-daily) products with dates and outcomes
Document side effects, allergies, or treatment failure for tried agents

Step Therapy

Initial Step-Therapy Requirements

Initial step-therapy requirements: First-line medications (preferred agents) are covered without prior authorization. Second-line medications will be covered if the member has filled at least two different first-line medications or a second-line medication within the past 180 days, or meets the specific clinical criteria for the named second-line agents below.

First-line agents: preferred long-acting (once-daily) ADHD medications — covered without PA
Second-line coverage triggers: at least two different first-line fills within the prior 180 days, OR a fill for a second-line agent within the prior 180 days

Drug Tier Definitions

Preferred first-line ADHD medications (no PA)

amphetamine/dextroamphetamine SRlisted as first-line (Compare to Adderall XR) — covered without prior authorization

methylphenidate SA tabletlisted as first-line (Compare to Concerta) — covered without prior authorization

dexmethylphenidate SR capsuleslisted as first-line (Compare to Focalin XR) — covered without prior authorization

methylphenidate CR capsuleslisted as first-line — covered without prior authorization

methylphenidate SA capsulelisted as first-line (Compare to Ritalin LA) — covered without prior authorization

Second-line products requiring prior authorization

Daytrana (methylphenidate patch)Second-line agent — requires prior authorization unless member meets criteria (diagnosis of ADD/ADHD or Narcolepsy AND trial and documented side effect, allergy, or treatment failure of two preferred long-acting products)

QuilliChew ER (methylphenidate hydrochloride)Second-line agent — requires prior authorization unless step-therapy criteria met (see Daytrana criteria)

Quillivant XR (methylphenidate hydrochloride suspension)Second-line agent — requires prior authorization unless step-therapy criteria met (see Daytrana criteria)

Dyanavel XR (amphetamine)Second-line agent — requires prior authorization unless member has tried two preferred long-acting products with documented intolerance or failure

Vyvanse (lisdexamfetamine)Second-line agent — requires prior authorization unless step-therapy criteria met; may also be approved for binge eating disorder or ADD/ADHD with required trials

Pharmacotherapy Options

inv-13: Pharmacotherapy (stimulant and nonstimulant agents)

Pharmacotherapy (stimulant and nonstimulant agents): Includes stimulant and nonstimulant pharmacotherapy options for ADHD; specific products listed include amphetamine/dextroamphetamine SR, methylphenidate formulations, and named second-line agents (Daytrana, QuilliChew ER, Quillivant XR, Dyanavel XR, Vyvanse)

See chunk 4 for product list; Vyvanse has alternative indication of binge eating disorder per chunk 7

Clinical Background

ADHD is commonly treated with stimulant agents including amphetamine and methylphenidate formulations. The policy lists specific products by agent and designates many commonly used formulations as first-line for automatic coverage, while naming several brand products as second-line (for example, Daytrana, QuilliChew ER, Quillivant XR, Dyanavel XR, and Vyvanse).

For second-line agents, approval requires meeting clinical criteria: the member must have the appropriate diagnosis and satisfy the step-therapy rules (for example, having filled at least two different first-line medications or a second-line medication within the past 180 days). Prior authorization is required when these step-therapy criteria are not met.