Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder 

Treatment: Vyvanse 30mg Capsules for 30-day supply

The insurer denied coverage for Vyvanse 30mg Capsules for 30-day supply

The denial is overturned.

This patient reportedly has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and had difficulty paying attention and listening, distractibility, concentration issues, forgetfulness, misplacement of items, interrupting others, talking too much in social situations and reportedly was taking Vyvanse 30 milligrams (mg) per day to target ADHD symptoms. It was reported that the patient had efficacy and no current reported side effects. It was reported that the patient was taking Vyvanse for 3 years with efficacy and current tolerability. The patient reportedly tried Adderall and had lack of efficacy reported. The patient also reportedly had past depressive and anxiety symptoms and took Zoloft in the past. The patient reportedly was in school and required Vyvanse to help with attention and subsequently her academic functioning. 
  
The insurer denied coverage for Vyvanse 30 mg per day stating that the patient did not try and fail or have intolerability or contraindication to formulary medications including amphetamine-dextroamphetamine, dexmethylphenidate, dextroamphetamine or methylphenidate. 
   
This reviewer disagrees with the decision to deny coverage for Vyvanse for this patient as the medical records support that this was considered medically necessary treatment then. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD. This patient had a diagnosis of ADHD and Vyvanse is considered an Food and Drug Administration (FDA) approved medication for ADHD and has a unique mechanism of action. Vyvanse (Lisdexamfetamine dimesylate) is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the other mentioned psychostimulants as it is a prodrug needing to be activated after ingestion. This medication's abuse potential is considered less than other psychostimulants. This patient reportedly tried and had lack of efficacy with Adderall which is amphetamine/dextroamphetamine which was on formulary. Since the patient was taking Vyvanse with reported efficacy for 3 years and current tolerability, Vyvanse was considered medically necessary treatment for this patient then. 

Although it was not likely that a formulary medication would cause adverse effects more than Vyvanse, it was not as likely that another methylphenidate product or dextroamphetamine/ amphetamine product would be more beneficial than trying Vyvanse which was different than these medication classes and FDA approved for ADHD and was reported to be effective for over 3 years. It was considered less likely that other methylphenidate and amphetamine/ dextroamphetamine medications still on formulary and the preferred list would be more effective than Vyvanse which has a unique mechanism of action. It did not appear that the health care plan acted in the best interests of the patient then.

The carrier's denial of a request for a Formulary Exception for Vyvanse 30mg Capsules for 30-day supply to treat ADHD is reversed.