CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Long-acting stimulant medications (Azstarys, Daytrana, Quillichew ER, lisdexamfetamine/Vyvanse) - Coverage Criteria

This policy governs prior authorization, continuation, and quantity limits for specified long-acting stimulant medications for ADHD and lisdexamfetamine for binge eating disorder for Neighborhood Health Plan of Rhode Island members (Medicaid scope noted).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLong-acting stimulant medications — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2021

Next Review DateN/A

Key ActionObtain documented diagnosis and required prior trial documentation (including two formulary long-acting stimulant trials for ADHD or required SSRI plus lisdexamfetamine trials for BED) to support prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration when criteria met

>=6min age — ADHD

>=18min age — BED

30 dayscontinuation paid-claim

09/01/2021

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.

Coverage Criteria

Initial Therapy Criteria

Covered when ALL of the following are met for initial approval (authorization of 12 months may be granted):

Overall: All criteria below must be met

ADHD Indication: Patient is 6 years of age or older AND has a documented diagnosis of attention deficit hyperactivity disorder (ADHD)

Applies to Azstarys, methylphenidate transdermal patch, Quillichew ER, or lisdexamfetamine chewable tablets

Prior stimulant trials for ADHD (one of the following): If request is for lisdexamfetamine chewable tablets, patient has documentation of having tried and failed two formulary long-acting stimulants for ADHD, with one being generic lisdexamfetamine capsules OR patient has documentation of tried and failed two formulary long-acting stimulants for ADHD (e.g., dexmethylphenidate ER, methylphenidate ER/CD/SR, amphetamine-dextroamphetamine ER/XR)2 failed trials

Provider may supply rationale if unable to try listed agents

BED Indication: Patient is 18 years of age or older AND has a documented diagnosis of moderate to severe binge eating disorder

Applies when lisdexamfetamine chewable tablets are requested

Prior trials for lisdexamfetamine in BED: For lisdexamfetamine chewable tablets, patient has documentation of having tried and failed two formulary selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, or sertraline) and generic lisdexamfetamine capsules, or a rationale why these agents are not appropriate2 failed SSRI trials plus generic lisdexamfetamine trial

Specific SSRIs listed in policy

Continuation Criteria

Continuation of therapy

Continuation: At least one paid claim for at least a 30-day supply within the last 365 days for the respective paid drug1 claim of >=30-day supply in 365 days

Allows continuation after initial approval

When reviewing requests for long‑acting stimulants, coverage is contingent on documentation that meets the policy’s specified age, diagnosis, and prior‑trial requirements. If the record does not clearly show the required age (for ADHD: ≥6 years; for BED when applicable: ≥18 years), a documented diagnosis, or the requisite prior medication trials described in the criteria (for example, documentation of two failed formulary long‑acting stimulant trials for ADHD or the SSRI plus generic lisdexamfetamine trials for BED), the request does not meet the approval criteria and authorization cannot be issued.

Requests lacking these elements should be treated as incomplete for the purpose of prior authorization determinations; providers should supply the missing age, diagnostic evidence, or prior‑trial documentation to support approval under the policy.

This policy’s coverage determinations require that all listed criteria be satisfied for approval. If any individual criterion is not met—such as absence of the documented diagnosis, failure to demonstrate the required prior medication trials, or the member not meeting the minimum age threshold—the request does not fulfill the policy’s conditions and is considered not medically necessary for authorization purposes. Providers may submit rationale or additional documentation if standard trials could not be completed for clinical reasons, but until such documentation is provided the policy implications stand.

Included Products and Limits

Included long-acting stimulant productsmixedCovered

Azstarys	serdexmethylphenidate/dexmethylphenidate (listed as included agent)
Daytrana (generic methylphenidate transdermal patch)	methylphenidate transdermal patch
Quillichew ER	methylphenidate chewable tablets
Vyvanse / lisdexamfetamine	lisdexamfetamine and lisdexamfetamine chewable tablets

Quantity limits per day — agent-specific limits

Azstarys (serdexmethylphenidate/dexmethylphenidate)Quantity limit: 1 capsule per day (strengths listed: 26.1/5.2 mg, 39.2/7.8 mg, 52.3/? mg)

Quillichew ER (methylphenidate chewable)Quantity limit: 1 chewable tablet per day (strengths listed: <20 mg, 30 mg, 40 mg)

Methylphenidate transdermal patch (Daytrana, generic)Quantity limit: 1 patch per day (strengths listed: 10 mg, 15 mg, 20 mg, 30 mg)

Lisdexamfetamine chewable tablets (Vyvanse/lisdexamfetamine)Quantity limit: 1 chewable tablet per day (strengths listed: 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for specified ADHD and binge eating disorder (BED) indications. Initial authorizations may be granted for up to 12 months when all clinical criteria are met.

Authorization duration: up to 12 months
Applicable products include: Azstarys, methylphenidate transdermal patch, Quillichew ER, lisdexamfetamine chewable tablets, and lisdexamfetamine capsules

Step Therapy

Step Therapy Requirements

Step therapy requires documented trials and failures of formulary long‑acting stimulants before approval for certain formulations; one of the prior trials may be generic lisdexamfetamine capsules when specified.

For lisdexamfetamine chewable tablets for ADHD: documentation of two formulary long‑acting stimulant trials/failures is required, with one trial being generic lisdexamfetamine capsules OR documentation of trials of two other formulary long‑acting stimulants (e.g., dexmethylphenidate ER, methylphenidate ER/CD/SR, amphetamine‑dextroamphetamine ER/XR).

Definitions

Continuation of therapy — operational definition

Operational definitionContinuation of therapy is defined as at least one paid claim for a 30-day supply of the drug within the last 365 days.

Lookback period365 days from the date of request to identify qualifying paid claims for continuation.

Minimum supply thresholdPaid claim must be for a supply of at least 30 days (not multiple shorter fills combined).

Pharmacotherapy (Stimulant and Lisdexamfetamine) Therapy

Pharmacotherapy (stimulant and lisdexamfetamine therapy)

Medication therapy

Pharmacotherapy: Use of long-acting stimulant formulations (Azstarys, methylphenidate transdermal patch/Daytrana, Quillichew ER, Vyvanse/lisdexamfetamine and lisdexamfetamine chewable tablets) per age and prior trial criteria

Includes ADHD and lisdexamfetamine for BED per policy

Background

Scope: This policy governs prior authorization, continuation, and quantity limits for specified long‑acting stimulant formulations used primarily for attention‑deficit/hyperactivity disorder (ADHD) and for lisdexamfetamine when used for moderate to severe binge eating disorder (BED). Included agents named in the policy include Azstarys, the methylphenidate transdermal patch (Daytrana), Quillichew ER, and lisdexamfetamine (including chewable formulations). The policy defines age thresholds and required prior‑trial documentation that must be met to authorize up to 12 months of therapy.