Stimulants

Drug - Stimulants

July 2016

Therapeutic Area - ADD/ADHD

Beginning July 5, 2016, stimulant medications will be limited to the maximum FDA approved daily dose.

Drug	Common brand names	Maximum daily dose
Amphetamine extended-release	Adzenys XR-ODT Dyanavel XR	18.8 mg/day (6-12 years); 12.5 mg (13 years and older) 20 mg/day
Atomexetine	Strattera	100 mg/day
Dexmethylphenidate	Focalin and generics	20 mg/day
Dexmethylphenidate extended-release	Focalin XR and generics	40 mg/day
Dextroamphetamine	Dexedrine, ProCentra,and generics	60 mg/day
Lixdexamfetamine	Vyvanse	70 mg/day
Methylphenidate	Ritalin and generics	60 mg/day
Methylphenidate extended-release	Concerta and generics Aptensio XR	72 mg/day 60 mg/day
Methylphenidate patches	Daytrana	30 mg/day
Methylphenidate solution, suspension	Quillivant XR	60 mg/day
Methylphenidate chewable tablets	Quillichew ER	60 mg/day
Mixed amphetamine salts	Adderall, Adderall XR*, generics	60 mg/day

Approval criteria

Patient must be 3 years of age or older AND
Patient must have a diagnosis of ADD or ADHD. Appropriate diagnosis code must be transmitted on prescription drug claim.
Requests must not exceed maximum daily dose as approved by the FDA

Quantity limits

Quantity requests exceeding the listed dose per day will be reviewed for medical necessity. Prescriber must provide evidence to support safety and additional efficacy of the higher than maximum doses as documented in published biomedical literature, demonstrating safety and efficacy of doses/quantities greater than those approved by the FDA for the diagnosis indicated.

Denial criteria

Treatment to suppress appetite
Treatment of obesity
Other off-label uses

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411