Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Narcolepsy
Treatment: Formulary exception for Methylphenidate 
Hydrochloride ER (Extended Release) 10 Milligram LA Cap
The insurer denied: Formulary exception for Methylphenidate Hydrochloride ER (Extended Release) 10 Milligram LA Cap
The denial is upheld

The patient is an adult female who was reported to have been diagnosed with narcolepsy without cataplexy (G47.419). The patient's provider is requesting the use of the nonformulary medication, methylphenidate ER LA (extended release) 10 mg (milligrams) capsule for treatment of the patient's excessive daytime sleepiness associated with narcolepsy. The requested medication was noted to have been previously denied coverage by the health plan, as there was no indication that the patient had failed to respond to at least three formulary alternatives or had contraindications or adverse effects to other preferred formulary alternatives available for treatment. The preferred formulary alternatives indicated include extended-release amphetamine/dextroamphetamine, extended-release dexmethylphenidate, extended-release dextroamphetamine, extended-release methylphenidate capsule and extended-release methylphenidate osmotic release tablet. The patient was noted to have been seen for a clinical encounter 2 months ago. She was noted to have been treated with Ritalin LA (extended release) 30 mg (milligrams) with good response. Diagnosis indicated was hypersomnia (G47.10). An appeal letter provided by the treating provider indicates that the patient is treated with methylphenidate ER LA 10 mg (milligrams) capsule for treatment of hypersomnia. The provider states that the patient had a 
diagnostic polysomnogram and multiple sleep latency test performed, which was consistent with narcolepsy/idiopathic hypersomnia.

The health plan should not cover the formulary exception for methylphenidate ER LA (extended release) 10 mg (milligrams) capsule.

The patient is an adult female who was reported to have been diagnosed with narcolepsy without cataplexy (G47.419). The patient's provider is requesting the use of the nonformulary medication, methylphenidate ER LA (extended release) 10 mg (milligrams) capsule for treatment of the patient's excessive daytime sleepiness associated with narcolepsy. There are several wake promoting medications that may be utilized for treatment of excessive daytime sleepiness associated with narcolepsy without cataplexy. The most commonly used wake promoting medications include methylphenidate and amphetamine-based stimulant medications. There are several formulations of methylphenidate and amphetamine-based stimulants that may be utilized for treatment of narcolepsy. There is no evidence in current peer-reviewed, evidence-based medical literature to indicate that methylphenidate ER LA (extended release) would be more effective or would have less adverse effects than other preferred long-acting stimulant formulations available for treatment. There is no evidence that other long-acting formulations have been ineffective in this patient. Therefore, the health plan should not cover the formulary exception for methylphenidate ER LA (extended release) 10 mg (milligrams) capsule.