ADHD and Narcolepsy Drugs

PHARM-13 Statement of Medical Necessity for Quantity Limits Override

ADHD and Narcolepsy Drugs

Drugs

Quantity Limits

Adderall XR (Amphet Asp/Amphet/D-Amphet) Capsules 5mg, 10mg, 15mg, 20mg, 25mg and 30mg Capsules

30 Capsules per 30 Days

Concerta (Methylphenidate HCL) SA Tablets
18mg, 27mg and 54mg 
36mg

30 Tablets per 30 Days
60 Tablets per 30 Days
Daytrana (Methylphenidate Transderm) Patches
10mg, 15mg, 20mg and 30mg 
30 Patches per 30 Days

Dexedrine (Dextroamphetamine Sulfate) SA Capsules
5mg and 10mg
15mg  

30 Capsules per 30 Days
120 Capsules per 30 Days

Dextrostat (Dextroamphetamine Sulfate)Tablets
5mg and 10mg  

30 Tablets per 30 Days

Focalin (Dexmethylphenidate HCL) Tablets
2.5mg, 5mg and 10mg

60 Tablets per 30 Days

Focalin XR (Dexmethylphenidate HCL) ER Capsules 
5mg,10mg, 15mg and 20mg

30 Capsules per 30 Days

Intuniv (Guanfacine HCL) SR Tablets
1mg, 2mg, 3mg and 4mg

30 Tablets per 30 Days

Metadate CD (Methylphenidate HCL) Capsules
10mg, 20mg, 30mg, 40mg, 50mg and 60mg  

30 Capsules per 30 Days

Methylin (Methylphenidate HCL) Chewable Tablets 
2.5mg, 5mg and 10mg

90 Tablets per 30 Days

Methylin (Methylphenidate HCL) Solution
5mg/5ml and 10mg/ml  

500 Mls per 30 Days
Nuvigil (Armodafinil) Tablets
50mg, 150mg and 250mg
 
30 Tablets per 30 Days

Provigil (Modafinil) 100mg and 200mg Tablets

30 Tablets per 30 Days

Ritalin (Methylphenidate HCL) Tablets
5mg, 10mg and 20mg

90 Tablets per 30 Days

Ritalin LA (Methylphenidate HCL) Capsules
10mg, 20mg and 40mg
30mg  

30 Capsules per 30 Days            
60 Capsules per 30 Days          
 
Vyvanse (Lisdexamfetamine Dimesylate) Capsules 
20mg, 30mg, 40mg, 50mg, 60mg and 70mg 
 
30 Capsules per 30 Days

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