Prior Authorization : Preferred Drug List

Stimulants

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Note: Some drugs in the stimulants drug class are designated as legacy stimulant drugs. For more information about designated legacy drugs in this drug class, providers may refer to the Legacy Exemptions for Stimulant Drugs topic.

Drugs in this class are diagnosis restricted. A ForwardHealth-allowed diagnosis code must be indicated on claims (and PA requests when applicable) for all stimulant drugs.

PA requests for non-preferred stimulants (except for methamphetamine) must be submitted on the PA/PDL for Non-Preferred Stimulants form.

Adderall, Dexedrine, dextroamphetamine-amphetamine, dextroamphetamine solution, dextroamphetamine tablets, Evekeo, and Zenzedi are non-preferred drugs; however, PA for Adderall, Dexedrine, dextroamphetamine-amphetamine; dextroamphetamine solution, dextroamphetamine tablets, Evekeo, or Zenzedi is not required for members who are 6 years of age or younger. Once a member reaches 7 years of age, PA will be required.

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Non-Preferred Stimulants

Clinical PA is required for non-preferred stimulants.

Clinical criteria for approval of a PA request for a non-preferred stimulant are both of the following:

• At least one of the following is true:
  • The member took Vyvanse for at least 60 consecutive days with a minimum of one dosage adjustment and experienced an unsatisfactory therapeutic response.
  • The member took Vyvanse and experienced a clinically significant adverse drug reaction.
• At least one of the following is true:
  • The member took a methylphenidate stimulant for at least 60 consecutive days with a minimum of one dosage adjustment and experienced an unsatisfactory therapeutic response.
  • The member took a methylphenidate stimulant and experienced a clinically significant adverse drug reaction.
  • The member took a dexmethylphenidate stimulant for at least 60 consecutive days with a minimum of one dosage adjustment and experienced an unsatisfactory therapeutic response.
  • The member took a dexmethylphenidate stimulant and experienced a clinically significant adverse drug reaction.

Submitting PA Requests for Non-Preferred Stimulants

PA requests for non-preferred stimulants (except for methamphetamine) must be completed and signed by the prescriber and must be submitted using the PA/PDL for Non-Preferred Stimulants form.

PA requests for non-preferred stimulants (except for dextroamphetamine-amphetamine ER or methamphetamine requests) may be submitted using the STAT-PA system, on the Portal, by fax, or by mail.

Methamphetamine

PA requests for methamphetamine should be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form and the PA/RF.

PA requests for methamphetamine may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Methamphetamine

Clinical criteria that must be documented for approval of a PA request for methamphetamine are all of the following:

• The member is 6–17 years of age.
• The member has had neuropsychological/psychological assessment that supports a diagnosis of ADHD.
• The prescriber has provided documented and objective evidence (supplied by third-party, unrelated adult observers) of functioning deficits secondary to ADHD in at least two of the following domains of functioning:
  • Home
  • Work
  • School
  • Community
• At least one of the following is true:
  • The member took Vyvanse for at least 60 consecutive days with a minimum of one dosage adjustment and experienced an unsatisfactory therapeutic response.
  • The member took Vyvanse and experienced a clinically significant adverse drug reaction.
• At least one of the following is true:
  • The member took a methylphenidate stimulant for at least 60 consecutive days with a minimum of one dosage adjustment and experienced an unsatisfactory therapeutic response.
  • The member took a methylphenidate stimulant and experienced a clinically significant adverse drug reaction.
• At least one of the following is true:
  • The member took a dexmethylphenidate stimulant for at least 60 consecutive days with a minimum of one dosage adjustment and experienced an unsatisfactory therapeutic response.
  • The member took a dexmethylphenidate stimulant and experienced a clinically significant adverse drug reaction.

PA requests must include medical records to support the above criteria have been met, including documentation of all past and current treatments that have been attempted (both pharmacologic and non-pharmacologic).

If clinical criteria for methamphetamine are met, PA requests will be approved for up to 183 days.

Stimulants and Stimulants, Related Agents – Wake Promoting Quantity Limits

Quantity limits apply to armodafinil, modafinil, Sunosi, and all preferred and non-preferred stimulants, with the exception of liquid dosage forms. Quantity limits do not apply to liquid dosage forms of stimulants. When a claim is submitted with a quantity that exceeds the limit, the claim will be denied.

The following applies to drugs in the stimulants drug class and the stimulants, related agents – wake promoting drug class:

• Armodafinil, modafinil, Sunosi, and all preferred and non-preferred stimulants (with the exception of liquid dosage forms) have a cumulative quantity limit of 136 units per month for drugs in the stimulants drug class and the stimulants, related agents – wake promoting drug class.
• Members are limited to a combined total of 136 units (tablets, capsules, or patches) per month, an exception being members with narcolepsy.
• Members with narcolepsy are allowed a quantity limit override to receive up to 136 units of stimulants in addition to 250 mg of armodafinil or 400 mg of modafinil or 150 mg of Sunosi per day.
• Azstarys and Xelstrym also have a drug-specific quantity limit of 34 units per month.

The Quantity Limit Drugs and Diabetic Supplies data table contains the most current quantity limits.

Overriding the Stimulants and Stimulants, Related Agents – Wake Promoting Quantity Limit Policy

Prior to requesting a quantity limit policy override, the pharmacy provider should contact the prescriber to determine whether or not it is medically appropriate for a member to exceed the quantity limit.

If it is medically appropriate for a member to exceed a quantity limit, pharmacy providers may request a quantity limit policy override by calling the DAPO Center.

Note: Providers are reminded that they may dispense up to the allowed quantity limit without contacting the DAPO Center.

Pharmacy providers may request a quantity limit policy override for members enrolled in BadgerCare Plus, Wisconsin Medicaid, or SeniorCare.

A quantity limit override request for drugs in the stimulants drug class and the stimulants, related agents – wake promoting drug class is limited to a one-month override and may be approved for the following situations:

• Lost or stolen medication
• Vacation supply
• Medication and/or dosage change by the prescriber

In addition, pharmacy providers may request a quantity limit policy override for members with narcolepsy. Members with narcolepsy are allowed a quantity limit override to receive up to 136 units of stimulants in addition to 250 mg of armodafinil or 400 mg of modafinil or 150 mg of Sunosi per day.

If the member does not meet the policy for a stimulants quantity limit override through the DAPO Center, and the claim submitted exceeds the allowed stimulants quantity limit, the claim will be denied and the service will be a noncovered service. Members do not have appeal rights for noncovered services.