Limited Coverage Drugs – Lisdexamfetamine

Generic Name

lisdexamfetamine

Strength

 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg

Form

 capsule

Special Authority Criteria

Approval Period

For patients 6 to 18 years of age diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) who require 12 hours of continuous coverage for hyperactivity, impulsivity, or inattention that interferes with functioning AND have been previously tried on one of the following with unsatisfactory results* or intolerance:

  • immediate‑ or sustained-release methylphenidate

OR

  • immediate- or sustained-release dextroamphetamine.

* See Special Notes below

Up to the patient’s 19th birthday.

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • “Unsatisfactory results” is defined as no demonstrated effectiveness for symptoms of ADHD or functional impairment secondary to ADHD after a minimum 1 week trial of an adequate dose of immediate- or sustained-release medication. Specific details of drug, dose and duration tried, and unsatisfactory response are required, as applicable.
  • Coverage is not intended for “performance enhancement” in children or youth who do not have symptoms or functional impairment.

Special Authority Request Forms