ADHD Drugs
PDL Reference Documents
Drug Use Review Documents
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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| amphetamine sulfate | AMPHETAMINE SULFATE | TABLET | Y | Age and Quantity Limits | N | |
| amphetamine sulfate | EVEKEO | TABLET | Y | Age and Quantity Limits | N | |
| atomoxetine HCl | ATOMOXETINE HCL | CAPSULE | Y | Age and Quantity Limits | Y | |
| dexmethylphenidate HCl | DEXMETHYLPHENIDATE HCL ER | CPBP 50-50 | Y | Age and Quantity Limits | N | |
| dexmethylphenidate HCl | FOCALIN XR | CPBP 50-50 | Y | Age and Quantity Limits | N | |
| dextroamphetamine sulfate | DEXTROAMPHETAMINE SULFATE ER | CAPSULE ER | Y | Age and Quantity Limits | N | |
| dextroamphetamine/amphetamine | ADDERALL XR | CAP ER 24H | Y | Age and Quantity Limits | N | |
| dextroamphetamine/amphetamine | DEXTROAMPHETAMINE-AMPHET ER | CAP ER 24H | Y | Age and Quantity Limits | N | |
| guanfacine HCl | INTUNIV | TAB ER 24H | Y | Y | ||
| lisdexamfetamine dimesylate | VYVANSE | CAPSULE | Y | Age and Quantity Limits | N | May 26, 2016 |
| lisdexamfetamine dimesylate | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | Y | Age and Quantity Limits | N | |
| methylphenidate | METHYLPHENIDATE | PATCH TD24 | Y | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLPHENIDATE HCL ER (CD) | CPBP 30-70 | Y | Age and Quantity Limits | N | |
| methylphenidate HCl | CONCERTA | TAB ER 24 | Y | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLPHENIDATE HCL | TABLET | Y | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLPHENIDATE ER | TABLET ER | Y | Age and Quantity Limits | N | |
| clonidine HCl | ONYDA XR | SUS ER 24H | V | Y | ||
| amphetamine | DYANAVEL XR | SUS BP 24H | N | Age and Quantity Limits | N | |
| amphetamine | ADZENYS XR-ODT | TAB RAP BP | N | Age and Quantity Limits | N | |
| dextroamphetamine sulfate | DEXTROAMPHETAMINE SULFATE | SOLUTION | N | Age and Quantity Limits | N | |
| dextroamphetamine sulfate | ZENZEDI | TABLET | N | Age and Quantity Limits | N | |
| dextroamphetamine/amphetamine | DEXTROAMPHETAMINE-AMPHET ER | CPTP 24HR | N | Age and Quantity Limits | N | |
| methamphetamine HCl | METHAMPHETAMINE HCL | TABLET | N | Age and Quantity Limits | N | |
| methylphenidate HCl | RITALIN LA | CPBP 50-50 | N | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLPHENIDATE ER (LA) | CPBP 50-50 | N | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLIN | SOLUTION | N | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLPHENIDATE HCL | SOLUTION | N | Age and Quantity Limits | N | |
| methylphenidate HCl | QUILLIVANT XR | SU ER RC24 | N | Age and Quantity Limits | N | |
| methylphenidate HCl | METHYLPHENIDATE ER | TAB ER 24 | N | Age and Quantity Limits | N | |
| serdexmethylphen/dexmethylphen | AZSTARYS | CAPSULE | N | Age and Quantity Limits | N |