Us Family Health Plan Pharmacy Program Medical Necessity Form For Vyvanse Page 3
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1
2
3Pharmacy Program Medical Necessity
Form for Vyvanse
This form applies to the US Family Health Plan Mail Order Pharmacy and the US Family Health Plan Retail Pharmacy programs. This form must be completed and signed by
the prescriber.
Medications for Attention-Deficit / Hyperactivity Disorder (ADHD) available at the formulary copay include Adderall/Adderall XR (generics),
Concerta (generics), Metadate CD, Ritalin LA, Strattera, immediate/sustained release methylphenidate, dextroamphetamine, and methamphetamine.
Daytrana (methylphenidate patch), Focalin (immediate release dexmethylphenidate), Focalin XR (extended release dexmethylphenidate),
and Vyvanse (lisdexamfetamine) are non-formulary, but available to most beneficiaries at the nonformulary cost share. NOTE: This form
applies to Vyvanse. A separate form applies to Daytrana, Focalin, and Focalin XR.
You do NOT need to complete this form in order for non-active duty beneficiaries (spouses, dependents, and retirees) to obtain Vyvanse at the non-
formulary cost share. The purpose of this form is to provide information that will be used to determine if the use of Vyvanse instead of a formulary
ADHD medication is medically necessary. If Vyvanse is determined to be medically necessary, non-active duty beneficiaries may obtain it at the $9
formulary cost share.
• The provider may call:
or the completed form may be faxed to:
• The patient may attach the completed form to the prescription and mail
it to: ATTN: Pharmacy, 77 Warren St, Brighton, MA 02135
Step
Please complete patient and physician information
(Please Print)
1
Patient Name:
Physician Name:
Address:
Address:
Sponsor ID #
Phone #:
Date of Birth:
Secure Fax #:
Step
Please explain why the patient cannot be treated with any of the formulary alternatives:
Please indicate which of the reasons below (1-3) applies to each of the formulary alternatives listed in the table. You
2
MUST circle a reason AND supply a written clinical explanation specific for EACH formulary alternative.
Formulary Alternative
Reason
Clinical Explanation
Extended release methylphenidate
(e.g., Concerta, Metadate CD, Ritalin
1 2 3
LA)
Extended release mixed amphetamine
1 2 3
salts (Adderall XR)
Note: The formulary alternatives listed above only include the extended release stimulant products.
Acceptable clinical reasons for not using a formulary alternative are:
1. Use of the formulary alternative is contraindicated (e.g., due to hypersensitivity).
2. The patient has experienced significant adverse effects from the formulary alternative.
3. Use of the formulary alternative has resulted in therapeutic failure.
I certify the above is true to the best of my knowledge. Please sign and date:
Step
3
Prescriber Signature
Date
Latest revision: 28 September 2011
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