ADHD Drugs

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
atomoxetine HCl ATOMOXETINE HCL CAPSULE Y Age and Quantity Limits  
atomoxetine HCl STRATTERA CAPSULE Y Age and Quantity Limits  
dexmethylphenidate HCl DEXMETHYLPHENIDATE HCL ER CPBP 50-50 Y Age and Quantity Limits  
dexmethylphenidate HCl FOCALIN XR CPBP 50-50 Y Age and Quantity Limits  
dexmethylphenidate HCl DEXMETHYLPHENIDATE HCL TABLET Y Age and Quantity Limits  
dexmethylphenidate HCl FOCALIN TABLET Y Age and Quantity Limits  
dextroamphetamine/amphetamine ADDERALL XR CAP ER 24H Y Age and Quantity Limits  
dextroamphetamine/amphetamine DEXTROAMPHETAMINE-AMPHET ER CAP ER 24H Y Age and Quantity Limits  
dextroamphetamine/amphetamine DEXTROAMPHETAMINE-AMPHETAMINE TABLET Y Age and Quantity Limits  
dextroamphetamine/amphetamine ADDERALL TABLET Y Age and Quantity Limits  
lisdexamfetamine dimesylate VYVANSE CAPSULE Y Age and Quantity Limits May 26, 2016
methylphenidate DAYTRANA PATCH TD24 Y Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE HCL CD CPBP 30-70 Y Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE HCL ER CPBP 30-70 Y Age and Quantity Limits  
methylphenidate HCl RITALIN TABLET Y Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE HCL TABLET Y Age and Quantity Limits  
clonidine HCl CLONIDINE HCL ER TAB ER 12H V Age and Quantity Limits  
clonidine HCl KAPVAY TAB ER 12H V Age and Quantity Limits  
guanfacine HCl INTUNIV TAB ER 24H V Age and Quantity Limits  
guanfacine HCl GUANFACINE HCL ER TAB ER 24H V Age and Quantity Limits  
amphetamine DYANAVEL XR SUS BP 24H N Age and Quantity Limits  
amphetamine ADZENYS XR-ODT TAB RAP BP N Age and Quantity Limits  
amphetamine sulfate EVEKEO TABLET N Age and Quantity Limits  
dextroamphetamine sulfate DEXEDRINE CAPSULE ER N Age and Quantity Limits  
dextroamphetamine sulfate DEXTROAMPHETAMINE SULFATE ER CAPSULE ER N Age and Quantity Limits  
dextroamphetamine sulfate DEXTROAMPHETAMINE SULFATE SOLUTION N Age and Quantity Limits  
dextroamphetamine sulfate PROCENTRA SOLUTION N Age and Quantity Limits  
dextroamphetamine sulfate DEXEDRINE TABLET N Age and Quantity Limits  
dextroamphetamine sulfate DEXTROAMPHETAMINE SULFATE TABLET N Age and Quantity Limits  
dextroamphetamine sulfate ZENZEDI TABLET N Age and Quantity Limits  
dextroamphetamine/amphetamine MYDAYIS CPTP 24HR N Age and Quantity Limits  
lisdexamfetamine dimesylate VYVANSE TAB CHEW N Age and Quantity Limits  
methamphetamine HCl DESOXYN TABLET N Age and Quantity Limits  
methamphetamine HCl METHAMPHETAMINE HCL TABLET N Age and Quantity Limits  
methylphenidate COTEMPLA XR-ODT TAB RAP BP N Age and Quantity Limits  
methylphenidate HCl RITALIN LA CPBP 50-50 N Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE ER CPBP 50-50 N Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE LA CPBP 50-50 N Age and Quantity Limits  
methylphenidate HCl APTENSIO XR CSBP 40-60 N Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE HCL SOLUTION N Age and Quantity Limits  
methylphenidate HCl METHYLIN SOLUTION N Age and Quantity Limits  
methylphenidate HCl QUILLIVANT XR SU ER RC24 N Age and Quantity Limits  
methylphenidate HCl QUILLICHEW ER TAB CBP24H N Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE HCL TAB CHEW N Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE ER TAB ER 24 N Age and Quantity Limits  
methylphenidate HCl CONCERTA TAB ER 24 N Age and Quantity Limits  
methylphenidate HCl METHYLPHENIDATE ER TABLET ER N Age and Quantity Limits  
methylphenidate HCl METADATE ER TABLET ER N Age and Quantity Limits