Dear Valued Provider,

Effective October 01, 2016, generic Adderall XR (amphetamine/dextroamphetamine ER capsule) will no longer be a preferred product. Amphetamine/dextroamphetamine ER capsules (generic Adderall XR) will require a Prior Authorization by Blue Cross and Blue Shield of Wyoming until more manufacturers become available or the price of the drug decreases. The innovator product Adderall XR will continue to be covered at the lower, generic drug (1st tier) cost share.*

Please note that this change in coverage may impact the inventory needed to provide for these Covered Persons. Consider ordering the brand name product in anticipation to minimize Covered Person disruption.

Action Required

If a participating pharmacy receives a prescription for amphetamine/dextroamphetamine ER capsules they will need to submit brand name Adderall XR in order to receive a paid claim. If a prescription for amphetamine/dextroamphetamine ER capsules is submitted instead of brand name Adderall XR, the claim will reject at point-of-sale (POS) with the following reject message:

• NCPDP Reject Code 70: "Prod/Service Not Covered"
• Secondary Message: "Generic not covered, Adderall XR covered. Please resubmit for brand. Adderall XR pays at Tier 1 benefit"

For questions regarding coverage of Adderall XR or the generic product, please refer Covered Persons to the Customer Service number on the back of their Blue Cross and Blue Shield of Wyoming ID card.

If you have any questions regarding claims processing, please call the Prime Contact Center at 800.821.4795.

Sincerely,

Pharmacy Network Management

Prime Therapeutics LLC

*Coverage of Adderall XR is dependent on the Covered Person’s benefit plan.