Medicare AdvantagePrior AuthMedium impact
Lisdexamfetamine Products (Revised)
Humana·Psychiatry, Pediatrics, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2021
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has updated its prior authorization policy for lisdexamfetamine products (Vyvanse, Arynta, generic lisdexamfetamine). The policy maintains two distinct approval pathways: one for Binge Eating Disorder (BED) requiring age 18+ and moderate-to-severe diagnosis, and one for ADHD/ADD requiring age 6+ and prior failure/contraindication/intolerance to long-acting stimulants. All prescriptions require prior authorization with plan-year approval duration.
Action Required
By April 22, 2026 (policy revision date): Billing and prior authorization teams must ensure all lisdexamfetamine product prescriptions (Vyvanse capsules/chewables, Arynta oral solution, generic lisdexamfetamine) for Medicare Advantage members are submitted for prior authorization before dispensing. Verify BED claims include documentation of moderate-to-severe diagnosis and patient age 18+; verify ADHD/ADD claims include diagnosis documentation, patient age 6+, and evidence of prior treatment failure, contraindication, or intolerance to long-acting stimulants (e.g., methylphenidate ER). Update prior authorization templates and billing software rules to reflect these specific criteria. Claims submitted without meeting these criteria or without prior authorization will be denied. Providers should be educated on the black box warning and requirement to assess abuse/misuse risk before prescribing.