Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder. 
Treatment: Formulary exception for Adderall XR [amphetamine-dextroamphetamine ER (extended release)]
The insurer denied: Formulary exception for Adderall XR (amphetamine-dextroamphetamine ER)
The denial is overturned. 

The patient is an adult female diagnosed with attention deficit hyperactivity disorder (ADHD). The patient is prescribed brand Adderall XR (amphetamine-dextroamphetamine extended release). The patient has been prescribed this medication for over one year with a positive response and improved functioning with tolerability and without adverse effects. The patient is diagnosed with comorbid unspecified anxiety disorder treated with gabapentin. Additionally, the patient is diagnosed with autism spectrum disorder associated with problems with social cues contributing to the anxiety. There is no co-occurring substance use disorder in this case. An immediate-release 5 milligrams Adderall is prescribed as a booster dose in the afternoon. The health plan has denied coverage of the Adderall XR (amphetamine-dextroamphetamine mixed salts extended-release formulation), indicating that the patient does not have evidence for treatment failure with at least three required health plan formulary alternatives. The formulary alternatives include amphetamine-dextroamphetamine extended release, dexmethylphenidate extended release, and Azstarys (step therapy). The health plan's medical necessity criteria indicates that a coverage exception would be allowed if the patient cannot be switched to a formulary alternative medication. The patient's clinician has requested a coverage exception based on the clinical history of a positive response with tolerability and improved functioning. The prescribing clinician appeals that the requested brand Adderall XR (extended release) is medically necessary to provide consistent and effective ongoing treatment for the patient's ADHD (attention deficit hyperactivity disorder), and that the patient has been taking the Adderall XR (extended release) that has successfully worked with tolerability for over one year. Additionally, the appeal asserts that to discontinue a medication that is working well would be "cruel" and detrimental to the patient, as the patient's symptoms of ADHD (attention deficit hyperactivity disorder) are well controlled, and that the continued use of Adderall XR (extended release) is the "best treatment" for this patient. 

In this case scenario, the health plan should cover the formulary exception for Brand Adderall XR (extended release). 

The submitted information from the prescribing clinician indicates that the patient has been effectively treated for over one year with the requested medication with tolerability and a favorable clinical response. Brand Adderall XR (amphetamine-dextroamphetamine extended release) demonstrates therapeutic benefits and a satisfactory response, as well as tolerability. Based upon the submitted information, the formulary drugs would not be or has not been effective for this patient as the requested non-formulary drug, which has been effective and tolerated for over one year. The likelihood of adverse effects with formulary alternatives and health plan preferences would be greater than the requested medication, Brand Adderall XR (extended release), for this patient with a reasonable degree of medical certainty. Moreover, to discontinue a medication that is effective and tolerated would pose risk for a recrudescence of symptoms of ADHD (attention deficit hyperactivity disorder) and would be detrimental to this patient. Thus, the health plan's denial reason is not reasonable or in the patient's best interest. The requested benefit of a Formulary exception for Adderall XR (extended release) for the purpose of treating ADHD (attention deficit hyperactivity disorder), is clinically appropriate and indicated; and is entirely consistent with nationally recognized guidelines and scientific evidence as referenced below, and consistent with prevailing medical standards.