Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)

Treatment: Mydayis 25 mg (milligram)

The insurer denied coverage for Mydayis 25 mg

The denial is upheld

This male reportedly had a diagnosis of attention deficit hyperactivity disorder (ADHD) and the request was for Mydayis 25 mg to treat his ADHD symptoms. There were no medical records documenting past ADHD medication treatment trials or medical conditions as a contraindication to the requested formulary preferred medications to treatment ADHD.
  
The insurer denied coverage for Mydayis 25 mg per day to treat his ADHD stating that there was no documentation supporting that he tried and failed with lack of efficacy, had adverse effects or contraindication to the formulary medications such as Adderall XR (extended release), Methylphenidate ER (extended release), Desmethylphenidate ER, or Atomoxetine.
  
There was no documentation provided in the medical records supporting that he tried and failed with lack of efficacy, had adverse effects, or contraindication to the formulary medications such as Adderall XR, Methylphenidate ER, Desmethylphenidate ER, or Atomoxetine. There were no reports that the patient tried formulary FDA (Food and Drug Administration) approved methylphenidate or amphetamine products such as Adderall XR, Methylphenidate ER, Desmethylphenidate ER, which are FDA approved medications for ADHD and also were on formulary. There also was no documentation in the medical records provided that he tried and failed atomoxetine which is a nonstimulant medication FDA approved for ADHD and was on formulary. The AACAP (American Academy of Child and Adolescent Psychiatry) Practice Parameters for the Assessment and Treatment of Children and Adolescents and Adults with ADHD reports that short term efficacy of psychopharmacological interventions for ADHD were well established. It also reports that stimulants were considered highly efficacious in the treatment of ADHD with up to 75% clinical responders. It states that physicians can chose from 2 stimulant types-methylphenidate or amphetamines because evidence suggests equal efficacy in the treatment of ADHD. In this case the request was for Mydayis 24 mg per day. Mydayis is a mixed salt with a mixture of 3:1 dextro to levo amphetamine. It is FDA approved for ages 13 and older. It comes in dosages of 12.5, 25, 37.5, and 50 mg. It has 3 types of drug releasing beads with one intermediate and 2 different delayed release beads. It reportedly reaches peak plasma levels in 8 hours. It is advantageous for longer duration of time coverage as it is dispensed once per day. The medical records provided for review did not provide enough specific evidence to support that he could only take this medication, Mydayis, for the treatment of ADHD. There were no reports that the other formulary medications FDA approved for ADHD such as methylphenidate or amphetamine products or Atomoxetine were tried and failed, or adverse effects occurred from them, or that he was unable to take them. There was no specific evidence or provided documentation that formulary medication likely would cause an adverse reaction or would be ineffective based on past clinical history, or that the requested medication of Mydayis would be more effective than the FDA approved formulary medications. As a result, the recommendation is to uphold the previous decision and deny coverage for Mydayis 25 mg. It appeared that the health care plan acted reasonably and with sound medical judgment then. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Formulary Exception for Mydayis 25 milligrams (mg) OR (oral) CP (capsule) 24 hour is upheld.