Xelstrym — United Healthcare
Patients unable to ingest solid dosage forms requiring stimulant therapy
Preferred products
- amphetamine/dextroamphetamine ER
- methylphenidate ER capsules
- dexmethylphenidate ER
Initial criteria
- Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR utilizes a feeding tube for medication administration
- AND Patient has a history of trial and failure, intolerance or contraindication to BOTH of the following: amphetamine/dextroamphetamine ER (generic Adderall XR) opened and sprinkled on soft food AND ONE of methylphenidate ER capsules (generic Metadate CD, Ritalin LA) opened and sprinkled on soft food OR dexmethylphenidate ER (generic Focalin XR) opened and sprinkled on soft food
Approval duration
12 months