| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Pharmacy | | 05/18/2024 | Prior Authorization : Preferred Drug ListTopic #10662 Legacy Exemptions for Stimulant Drugs
BadgerCare Plus, Medicaid, and SeniorCare members who were granted a legacy exemption for designated amphetamine drugs for DOS on and after January 1, 2018, and remained eligible throughout 2023, will no longer be allowed to receive the legacy exemption for amphetamine drugs for DOS on and after January 1, 2024, if one of the following is true:
- Members without other primary insurance on file with ForwardHealth who have had no claim activity for amphetamine drugs for DOS in the last six months of 2023
- Members with other primary insurance on file with ForwardHealth who have had no claim activity for amphetamine drugs for DOS in calendar year 2023
Note: A member's legacy exemption for designated amphetamine drugs overrides the PDL PA policy only. Other policies continue to apply, such as member enrollment eligibility, diagnosis restriction, quantity limits, and noncovered service policies.
The table below lists the allowed legacy exemptions for amphetamine drugs and their applicable legacy exemption details.
Note: A legacy exemption is not applied to dextroamphetamine-amphetamine ER because the drug requires BBG PA. In addition to meeting established BBG criteria, PA requests for dextroamphetamine-amphetamine ER must also meet the clinical criteria for non-preferred stimulants.
Drugs in the stimulants drug class are diagnosis restricted. A ForwardHealth-allowed diagnosis code must be indicated on claims (and PA requests when applicable) for all stimulant drugs.
| Designated Legacy Exemptions for Stimulant Drugs | Details |
| Dexedrine Spansule
dextroamphetamine
dextroamphetamine ER |
Eligible members identified to be taking any one of these three drugs are allowed to receive any of the following as a legacy exemption stimulant drug:
- Brand name Dexedrine Spansule
- Generic dextroamphetamine
- Generic dextroamphetamine ER
Note: An approved PA request is not required for any child 6 years of age or younger for generic dextroamphetamine.
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| Adderall
Adderall XR
dextroamphetamine-amphetamine |
Eligible members identified to be taking any one of these three drugs are allowed to receive any of the following as a legacy exemption stimulant drug:
- Adderall
- Adderall XR
- Generic dextroamphetamine-amphetamine
Note: For members allowed to receive brand name Adderall XR as a legacy exemption stimulant drug, ForwardHealth will automatically apply a generic copay to claims for brand name Adderall XR.
Note: An approved PA request is not required for any child 6 years of age or younger for brand name Adderall or generic dextroamphetamine-amphetamine.
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| Evekeo |
Eligible members identified to be taking this drug are allowed to receive this drug only as a legacy exemption stimulant drug.
Note: An approved PA request is not required for any child 6 years of age or younger for Evekeo.
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