STIMULANTS AND RELATED AGENTS | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ADDERALL 10 MG TABLET dextroamphetamine/amphetamine	57844011001 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL 12.5 MG TABLET dextroamphetamine/amphetamine	57844011201 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL 15 MG TABLET dextroamphetamine/amphetamine	57844011501 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL 20 MG TABLET dextroamphetamine/amphetamine	57844012001 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL 30 MG TABLET dextroamphetamine/amphetamine	57844013001 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL 5 MG TABLET dextroamphetamine/amphetamine	57844010501 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL 7.5 MG TABLET dextroamphetamine/amphetamine	57844011701 TEVA USA	Yes	No	Medicaid CHIP CSHCN
ADDERALL XR 10 MG CAPSULE dextroamphetamine/amphetamine	54092038301 TAKEDA PHARMACE	Yes	No	Medicaid CHIP CSHCN
ADDERALL XR 15 MG CAPSULE dextroamphetamine/amphetamine	54092038501 TAKEDA PHARMACE	Yes	No	Medicaid CHIP CSHCN
ADDERALL XR 20 MG CAPSULE dextroamphetamine/amphetamine	54092038701 TAKEDA PHARMACE	Yes	No	Medicaid CHIP CSHCN