Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Attention deficit hyperactivity disorder (ADHD).
Treatment:  Formulary Exception for Vyvanse 10 milligrams (mg) OR (oral) CAPS (capsules).
The insurer denied coverage for Formulary Exception for Vyvanse 10 mg OR CAPS.  The denial is upheld.

This adult had a diagnosis of ADHD-predominantly inattentive presentation and reported continued attention problems interfering with her functioning as a writer. She reportedly had tried other medications to target ADHD, including Adderall extended release (XR) and immediate release (IR) but had physical side effects and brain fog, Focalin, which resulted in a side effect of irritable mood, Atomoxetine, which was not effective and also resulted in a sexual side effect. She had a past trial of Vyvanse and had side effects of dissociative symptoms. The request by her mental health provider was to have a retrial of Vyvanse but at a low dose of 10 mg per day.
    
The patient did not meet the criteria used by the insurer. She did not try all of the preferred formulary medications first which included Adderall XR, Atomoxetine, Dexmethylphenidate, and Methylphenidate ER. She reportedly did try Adderall XR, Atomoxetine, Dexmethylphenidate and had side effects with all of them and also had lack of efficacy with Atomoxetine. 

However, there were no reports that she tried and had lack of efficacy or side effects or that there was a contraindication to the preferred formulary medication, Methylphenidate ER, so there was not specific evidence that she tried all formulary medications for ADHD. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with ADHD reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD. There are several different psychostimulants and Strattera, which are used to target ADHD symptoms. Psychostimulants include Methylphenidate ER (brand name is Concerta), which is a pump OROS-osmotic release oral system Methylphenidate using osmotic delivery system in which the tablet is coated with 22% (percent) immediate release Methylphenidate for the initial dosing, and the long duration component is delivered by osmotic pump that gradually releases Methylphenidate producing an ascending serum concentration to approximate a 3 times daily dosing schedule. There also is short acting Methylphenidate (brand name Ritalin). Also, other methylphenidate products include dexmethylphenidate ER agents, such as Focalin (brand name). Other types of psychostimulants include extended release dextroamphetamine (Adderall-brand name) both XR and short acting regular. Also, Strattera, which is the brand name for Atomoxetine, which is a nonstimulant blocking the presynaptic reuptake of norepinephrine neurons, is another Food and Drug Administration (FDA) approved medication for ADHD. Vyvanse is a brand name medication and is called Lisdexamfetamine dimesylate (generic), and it is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. 

There was no specific documentation in the medical records showing that this patient tried all of the other FDA approved formulary medications for ADHD. Furthermore, there was no specific evidence that Vyvanse is a better choice than the preferred and formulary medication, Methylphenidate ER, as she reportedly had side effects of dissociative symptoms with her previous trial of Vyvanse. 

It appeared that the insurer acted reasonably and with sound medical judgment.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not all tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non-formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Vyvanse 10 mg OR CAPS to treat ADHD is upheld.