CurrentMass General Brigham Health PlanPolicy N/A

Initial Step-Therapy Requirements — ADHD Stimulants Step Therapy

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Defines initial step-therapy requirements, coverage criteria, and quantity limits for stimulant medications used to treat ADHD under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyInitial Step-Therapy Requirements — ADHD Stimulants

Policy CodePolicy N/A

Change TypeMaterial revisions and additions

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateApr 15, 2026

Key ActionSubmit a prior authorization with prior-fill documentation or medical records (for members new to plan ≤90 days) when prescriptions do not meet initial step therapy at point of sale.

SourceLink

POLICY UPDATE CHANGES

Updated language for members who are new to the Plan and removed generic Daytrana from the policy.

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

Allowed approval of lisdexamfetamine (Vyvanse) for treatment of binge-eating disorder.

Added quantity limits for listed stimulant products.

12 monthsApproval duration

180 daysLookback period

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CurrentMass General Brigham Health PlanPolicy N/A

Initial Step-Therapy Requirements — ADHD Stimulants Step Therapy

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Policy Summary

PayerMass General Brigham Health Plan

PolicyInitial Step-Therapy Requirements — ADHD Stimulants

Policy CodePolicy N/A

Change TypeMaterial revisions and additions

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateApr 15, 2026

Key ActionSubmit a prior authorization with prior-fill documentation or medical records (for members new to plan ≤90 days) when prescriptions do not meet initial step therapy at point of sale.

SourceLink

POLICY UPDATE CHANGES

Updated language for members who are new to the Plan and removed generic Daytrana from the policy.

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

Allowed approval of lisdexamfetamine (Vyvanse) for treatment of binge-eating disorder.

Added quantity limits for listed stimulant products.

12 monthsApproval duration

180 daysLookback period

Step Therapy and Coverage Criteria

Step therapy coverage criteria

Covered when ALL of the following apply:

Member has a prescription for a stimulant medication under the pharmacy benefit.

ALL of the following

If the medication is listed as first-line, it is covered without prior authorization (first-line products listed in policy).N/A
If the medication is listed as second-line, it will adjudicate at point of sale ONLY if the member has filled at least two different first-line medications OR a second-line medication within the past 180 days (lookback period = 180 days).180 days
Evidence of prior fills will be verified at point of sale.

Exceptions allowing prior authorization

ONE of
- Member has had a trial and failure, adverse reaction, or contraindication to at least two first-line long-acting stimulants.
- Member has had a trial and failure with at least one second-line long-acting stimulant.
- Request is for lisdexamfetamine (Vyvanse) and the member has a diagnosis of binge-eating disorder.

For members new to the plan (coverage effective date ≤ 90 days), submission of medical records documenting current treatment with the requested drug may be used to support authorization (excluding samples or manufacturer's patient assistance programs).≤ 90 days

Approvals granted per policy limitations: authorizations are issued for up to 12 months and product-specific per-day quantity limits apply as listed in the policy.

Stimulant Product List and Operational Parameters

Stimulant product listmixed

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
amphetamine/dextroamphetamine 3-bead ER capsule	generic Mydayis
QuilliChew ER	methylphenidate hydrochloride tablet
Quillivant XR	methylphenidate hydrochloride suspension
Dyanavel XR	amphetamine oral suspension
Dyanavel XR	amphetamine tablet

1–10 of 11

1/2

Prior-fill lookback

Lookback period180 days — member must have filled at least two different first-line medications or a second-line medication within the past 180 days to qualify second-line at point of sale

What counts toward lookbackEither 2 distinct first-line stimulant fills OR a fill of any second-line stimulant within the prior 180 days

PurposeDetermines automatic point-of-sale adjudication for second-line products without requiring prior authorization

Adjudication, Prior Authorization, and Documentation

Prior Authorization

Initial adjudication and PA requirement

Prescriptions that meet the initial step therapy requirements will adjudicate automatically at the point of sale; prescriptions that do not meet the requirements will deny at point of sale with a message that prior authorization is required and a PA request must be submitted.

Step Therapy

Step therapy override criteria & required documentation

A second-line stimulant may be approved only when the member meets one of the listed override criteria; providers must document trials/failures/adverse reactions/contraindications or relevant diagnoses and prior fills as specified.

Approval granted if member has trial and failure, adverse reaction, or contraindication to at least two first-line long-acting stimulants.
Approval granted if member has trial and failure with at least one second-line long-acting stimulant.
Approval granted for lisdexamfetamine when the member has a diagnosis of binge‑eating disorder.

Key Definitions

First-line medications

DefinitionFirst-line medications are those listed as 'First-Line' in the policy and are covered without prior authorization.

Included productsamphetamine/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).

Additional formulations listed as first-lineQuilliChew ER (methylphenidate HCl) tablet; Quillivant XR suspension; Dyanavel XR oral suspension and tablet; Vyvanse (lisdexamfetamine) capsule.

Second-line requirements

DefinitionSecond-line medications are those not considered first-line and require evidence of prior trials or an approved exception for authorization.

Authorization without exception

Medication with Psychosocial Interventions

Medication plus psychosocial interventions

Medication should be used in conjunction with evidence-based psychosocial interventions when appropriate:

Pharmacologic treatment (stimulant medication) is expected to be provided alongside evidence-based psychosocial and behavioral interventions appropriate to the member's age and clinical needs (for example, behavioral parent training, school-based interventions, and cognitive-behavioral strategies as supported by referenced literature).