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

Last updated on March 17, 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) 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	Indefinite

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:

Immediate‑ or sustained-release methylphenidate

Immediate- or sustained-release dextroamphetamine

* See Special Notes below

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 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
Criteria applicable to all plans including Plan G

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