Limited coverage criteria – dextroamphetamine-amphetamine (mixed amphetamine salts)

Last updated on July 23, 2025

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Generic name	dextroamphetamine-amphetamine (mixed amphetamine salts)
Strength & form	5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg extended-release capsule

Special Authority criteria	Approval period
For patients 6 years of age and older diagnosed with attention-deficit hyperactivity disorder (ADHD) requiring 12 hours of continuous coverage for hyperactivity, impulsivity, or inattention that interferes with functioning who have previously tried one of the following therapies with unsatisfactory results¹ or intolerance: Immediate- or sustained-release Ritalin-type methylphenidate OR Immediate- or sustained-release Dexedrine-type dextroamphetamine	Indefinite

Special Authority criteria

Approval period

For patients 6 years of age and older diagnosed with attention-deficit hyperactivity disorder (ADHD) requiring 12 hours of continuous coverage for hyperactivity, impulsivity, or inattention that interferes with functioning who have previously tried one of the following therapies with unsatisfactory results¹ or intolerance:

Immediate- or sustained-release Ritalin-type methylphenidate

Immediate- or sustained-release Dexedrine-type dextroamphetamine

Indefinite

Practitioner exemptions

None

Special notes

"Unsatisfactory results" is defined as no demonstrated effectiveness for symptoms of ADHD or functional impairment secondary to ADHD after a minimum one-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
Criteria applicable to all plans including Plan G

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