Limited coverage criteria – lisdexamfetamine

Last updated on March 19, 2025

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Generic name	lisdexamfetamine
Strength & form	10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg 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‑release or sustained-release methylphenidate OR Immediate-release or sustained-release dextroamphetamine * Refer to 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‑release or sustained-release methylphenidate

Immediate-release or sustained-release dextroamphetamine

* Refer to 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
Criteria applicable to all plans, including Plan G

Special Authority request form(s)

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