Limited coverage drugs – lisdexamfetamine
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|
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 years of age and older 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:
OR
* See Special Notes below |
Indefinite |
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 patients who do not have symptoms or functional impairment.
