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    
ATOMOXETINE HCL STRATTERA CAPSULE Y    
DEXMETHYLPHENIDATE HCL FOCALIN XR CPBP 50-50 Y    
DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER CPBP 50-50 Y    
DEXMETHYLPHENIDATE HCL FOCALIN TABLET Y    
DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL TABLET Y    
DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE-AMPHETAMINE TABLET Y    
DEXTROAMPHETAMINE/AMPHETAMINE ADDERALL TABLET Y    
LISDEXAMFETAMINE DIMESYLATE VYVANSE CAPSULE Y   May 26, 2016
METHYLPHENIDATE DAYTRANA PATCH TD24 Y    
METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD CPBP 30-70 Y    
METHYLPHENIDATE HCL METHYLPHENIDATE HCL ER CPBP 30-70 Y    
METHYLPHENIDATE HCL METHYLPHENIDATE HCL TABLET Y    
METHYLPHENIDATE HCL RITALIN TABLET Y    
CLONIDINE HCL CLONIDINE HCL ER TAB ER 12H V Quantity Limit  
CLONIDINE HCL KAPVAY TAB ER 12H V Quantity Limit  
GUANFACINE HCL GUANFACINE HCL ER TAB ER 24H V Quantity Limit  
GUANFACINE HCL INTUNIV TAB ER 24H V Quantity Limit  
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 DEXTROAMPHETAMINE SULFATE ER CAPSULE ER N Age and Quantity Limits  
DEXTROAMPHETAMINE SULFATE DEXEDRINE 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 DEXTROAMPHETAMINE SULFATE TABLET N Age and Quantity Limits  
DEXTROAMPHETAMINE SULFATE ZENZEDI TABLET N Age and Quantity Limits  
DEXTROAMPHETAMINE/AMPHETAMINE ADDERALL XR CAP ER 24H N Age and Quantity Limits  
DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE-AMPHET ER CAP ER 24H 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 HCL RITALIN LA CPBP 50-50 N Age and Quantity Limits  
METHYLPHENIDATE HCL METHYLPHENIDATE LA CPBP 50-50 N Age and Quantity Limits  
METHYLPHENIDATE HCL METHYLPHENIDATE ER CPBP 50-50 N Age and Quantity Limits  
METHYLPHENIDATE HCL APTENSIO XR CSBP 40-60 N Age and Quantity Limits  
METHYLPHENIDATE HCL METHYLIN SOLUTION N Age and Quantity Limits  
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 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 METADATE ER TABLET ER N Age and Quantity Limits  
METHYLPHENIDATE HCL METHYLPHENIDATE ER TABLET ER N Age and Quantity Limits