Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Adderall amphetamine-dextroamphetamine 30 mg tablet; 20 mg tablet; 15 mg tablet; 5 mg tablet; 12.5 mg tablet; 7.5 mg tablet; 10 mg tablet   $$ Adderall XR amphetamine-dextroamphetamine 20 mg capsule,extended release 24hr; 30 mg capsule,extended release 24hr; 10 mg capsule,extended release 24hr; 5 mg capsule,extended release 24hr; 15 mg capsule,extended release 24hr; 25 mg capsule,extended release 24hr   Not Applicable Cafcit caffeine citrated 60 mg/3 mL (20 mg/mL) Solution     Not Applicable Concerta methylphenidate 18 mg tablet extended release 24hr; 54 mg tablet extended release 24hr; 36 mg tablet extended release 24hr; 27 mg tablet extended release 24hr   $$$$ Cylert Pemoline   Not Applicable Daytrana methylphenidate 10 mg/9 hr Patch 24 hr; 15 mg/9 hr Patch 24 hr; 20 mg/9 hr Patch 24 hr; 30 mg/9 hr Patch 24 hr   Not Applicable Desoxyn methamphetamine 5 mg tablet   Not Applicable Dexedrine dextroamphetamine 5 mg tablet   $$ DextroStat dextroamphetamine 5 mg tablet; 10 mg tablet   $$ Focalin dexmethylphenidate 5 mg tablet; 10 mg tablet; 2.5 mg tablet   $ Focalin XR dexmethylphenidate 15 mg capsule,ER multiphase 50-50   Not Applicable Focalin XR dexmethylphenidate 20 mg capsule,ER multiphase 50-50   Not Applicable Focalin XR dexmethylphenidate 5 mg capsule,ER multiphase 50-50; 10 mg capsule,ER multiphase 50-50   Not Applicable Liquadd dextroamphetamine 5 mg/5 mL Solution   Not Applicable Metadate CD methylphenidate 20 mg capsule, ER multiphase 30-70; 10 mg capsule, ER multiphase 30-70; 30 mg capsule, ER multiphase 30-70; 40 mg capsule, ER multiphase 30-70; 50 mg capsule, ER multiphase 30-70; 60 mg capsule, ER multiphase 30-70   Not Applicable Metadate ER methylphenidate 20 mg tablet extended release; 10 mg tablet extended release   $$ Nuvigil armodafinil 50 mg tablet; 150 mg tablet; 250 mg tablet   Not Applicable Provigil modafinil 100 mg tablet; 200 mg tablet   Not Applicable Quillivant XR methylphenidate 5 mg/ml suspension, extended release, reconst. 24hr   Not Applicable Ritalin methylphenidate 20 mg tablet; 10 mg tablet; 5 mg tablet   $$ Ritalin LA methylphenidate 20 mg capsule,ER multiphase 50-50; 40 mg capsule,ER multiphase 50-50; 10 mg capsule,ER multiphase 50-50   Not Applicable Ritalin LA methylphenidate 30 mg capsule,ER multiphase 50-50   Not Applicable Ritalin SR methylphenidate 20 mg tablet extended release   $$ Vyvanse lisdexamfetamine 30 mg capsule; 50 mg capsule; 70 mg capsule; 20 mg capsule; 40 mg capsule; 60 mg capsule   Not Applicable Xyrem sodium oxybate 500 mg/mL Solution   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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