Dexedrine Spansules — Medical Mutual

Attention-deficit hyperactivity disorder (ADHD)

Preferred products

Generic amphetamine/dextroamphetamine extended-release capsules (generics to Adderall XR)
Generic dexmethylphenidate extended-release capsules (generics to Focalin XR)
Generic dextroamphetamine extended-release capsules (generics to Dexedrine Spansules)
Generic lisdexamfetamine capsules
Generic methylphenidate extended-release capsules (generics to Metadate CD and Ritalin LA)
Metadate ER (generic according to FDB)
Generic methylphenidate sustained-release tablets (generics to Ritalin SR)
Generic methylphenidate extended-release tablets (generics to Concerta)
Generic mixed salts of a single-entity amphetamine product extended-release capsules (generic to Mydayis)

If the patient has tried one Preferred agent, authorization for a Non-Preferred agent may be given.

Extended approval: 2 years
Step Therapy Exception Criteria: Approve for 1 year if A OR B OR C:
A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents [documentation required]; OR
B. The patient has a contraindication to all preferred agents [documentation required]; OR
C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
1. Patient has at least 130 days of prescription claims history on file and claims history supports use of the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested non-preferred product (i.e. AA-rated or AB-rated); OR
2. When 130 days of prescription claims history is unavailable, the prescriber must verify 90 days of use of the requested non-preferred agent via paid claims (not samples, coupons, waivers) AND that there is no generic equivalent available for the requested non-preferred product (i.e. AA-rated or AB-rated)

Initial: 1 year; Extended: 2 years; Continuation: 1 year