Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder.
Treatment: Formulary exception for Adderall XR.
The insurer denied the Formulary exception for Adderall XR.
The denial is overturned. 

This case involves a male patient diagnosed with attention deficit hyperactivity disorder (ADHD), predominantly inattentive type. The patient has been effectively treated in the past seven years and currently with stimulant medication, brand Adderall XR (amphetamine-dextroamphetamine extended release) at a dosage of ten milligrams daily. The patient demonstrates therapeutic benefits and a satisfactory response, as well as tolerability. The patient had tolerability problems and a lack of response to various generic formulations of medications targeting attention deficit hyperactivity disorder ( ADHD) including generic Adderall XR (amphetamine-dextroamphetamine extended release). Exposure and treatment failure was not available for different generic formulations of stimulants and other medications approved for the treatment of attention deficit hyperactivity disorder (ADHD); the patient had relocated for work, and the prescribing clinician did not have the patient's treatment history in his record, and was unable to specify which medications had been tried and failed other than the generic formulation of Adderall XR. Again, the patient provided a history of treatment failure with generic formulations of stimulant or attention deficit hyperactivity disorder (ADHD) approved medications. Thus, the patient was prescribed the Brand Adderall XR at the effective dose of ten milligrams given the history of a satisfactory response for the past several years with regard to symptom relief and ability to function.

The health plan has denied coverage of the Adderall XR (amphetamine-dextroamphetamine mixed salts extended release formulation) at the effective dosage of ten milligrams daily indicating that the patient does not have evidence for treatment failure with the health plan's formulary alternatives which include amphetamine-dextroamphetamine extended release, atomoxetine, dextroamphetamine extended release, dexmethylphenidate extended release,  and methylphenidate extended release medications, as well as Vyvanse (lisdexamfetamine). Moreover, the health plan's Pharmacy Drug Policy indicates that the plan has a closed formulary that "provides high-quality and cost-effective prescription coverage." The health plan's Pharmacy Drug Policy and denial indicates that all formulary alternatives, as noted, must be tried and fail due to lack of efficacy or "serious" adverse effects before a coverage exception would be allowed. 

The patient's clinician has requested a coverage exception on the basis of the clinical history and the longstanding response to the brand formulation of Adderall XR at the effective dose of ten milligrams daily with tolerability. The prescribing clinician appeals that the requested Adderall XR is necessary in order to provide consistent and effective ongoing treatment for the patient's attention deficit hyperactivity disorder (ADHD).

Yes, in this case scenario, the health plan should cover the proposed treatment with Brand Adderrall XR ten milligram capsule sustained release (SR) 24 hours.
In this case, the patient record and submitted information from the prescribing clinician indicates that the patient has been effectively treated for the past several years with the requested medication with tolerability and a favorable clinical response. The new primary care clinician has continued treatment with stimulant medication, Brand Adderall XR (amphetamine-dextroamphetamine extended release) at a dosage of ten milligrams daily. Again, the patient demonstrates therapeutic benefits and a satisfactory response, as well as tolerability with the requested Brand Adderall, and the patient has a history of tolerability problems and a lack of response to various other generic formulations of medications targeting attention deficit hyperactivity disorder (ADHD) including generic Adderall XR (amphetamine-dextroamphetamine extended release).

Thus, based upon the submitted information and appeal-noted below; 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 several years. The likelihood of adverse effects with formulary alternatives and health plan preferences would be greater than the requested medication, Brand Adderall XR, for this patient. Moreover, to discontinue a medication that is effective and tolerated would pose risk for a recrudescence of symptoms of attention deficit hyperactivity disorder (ADHD) and be detrimental to this patient. Thus, the health plan's denial reason is not reasonable or in the patient's best interest whereas the health plan Pharmacy Drug Policy indicates that all formulary alternatives, as noted, must be tried and fail due to lack of efficacy or "serious" adverse effects before a coverage exception would be allowed. 

The patient's clinician has requested a coverage exception on the basis of the clinical history and the longstanding response to the brand formulation of Adderall extended release (XR) at the effective dose of ten milligrams daily with tolerability. The prescribing clinician appeals that the requested Adderall extended release (XR) is necessary in order to provide consistent and effective ongoing treatment for the patient's ADHD.