Us Family Health Plan Pharmacy Program Medical Necessity Form For Vyvanse

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Medical Necessity Criteria for Attention Deficit Hyperactivity Disorder (ADHD) Agents
Attention Deficit Hyperactivity Disorder (ADHD) and Narcolepsy Agents. This drug class includes agents
primarily used to treat ADHD, some of which have FDA indications for narcolepsy, as well as three agents that
are indicated for the treatment of narcolepsy, but not ADHD. After evaluating the relative clinical and cost
effectiveness of the ADHD and narcolepsy agents, the DoD P&T Committee recommended that the following
medications be designated as non-formulary. All of these medications are primarily used for ADHD. This
recommendation has been approved by the Director, TMA.
Effective Date: 18 April 2007
Daytrana (methylphenidate patch)
Focalin (dexmethylphenidate immediate release)
Focalin XR (dexmethylphenidate immediate release)
Effective Date: 16 April 2008
Daytrana (methylphenidate patch)
Patients currently using a nonformulary Attention Deficit Hyperactivity Disorder (ADHD) Agent may wish to ask
their doctor to consider a formulary alternative.
Special Notes:
1. Active duty cost share always $0 in all points of service for all three tiers; Active duty cost share always
$0 in all points of service for all three tiers; TRICARE does not cover non-formulary medications for
active duty service members unless they are determined to be medically necessary.
2. MTFs will be able to fill non-formulary requests for non-formulary medications only if both of the
following conditions are met: 1) a MTF provider writes the prescription, and 2) medical necessity is
established for the non-formulary medication. MTFs may (but are not required to) fill a prescription for a
non-formulary medication written by a non-MTF provider to whom the patient was referred, as long as
medical necessity has been established.
3. ADHD agents may be divided into two general groups: 1) stimulants (which include both amphetamine
products such as Adderall XR and Vyvanse, and methylphenidate products such as Concerta, Metadate
CD, and Ritalin LA) and 2) the non-stimulant atomoxetine (Strattera). Extended release formulations of
the stimulants are most commonly used, with immediate release fomulations reserved for dose titration
or for augmenting treatment during specific time periods. In most cases, Focalin (dexmethylphenidate
immediate release) would not be used as a sole therapy; therefore, medical necessity review is based
on extended release products only. Strattera is less commonly used than the stimulants and is often
reserved for specific patient groups (e.g., patients who cannot tolerate the adverse effects of
4. Accordingly, therapeutic alternatives to dexmethylphenidate (Focalin, Focalin XR), methylphenidate
patch (Daytrana), and lisdexamfetamine (Vyvanse) are considered to be the formulary extended release
stimulant products: extended release methylphenidate (e.g., Concerta, Metadate CD, Ritalin LA) and
extended release mixed amphetamine salts, (Adderall XR).


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