Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety Disorder

Treatment Xanax 1 milligram (mg) 5 tablets per day

The insurer denied coverage for Xanax 1 milligram (mg) 5 tablets per day

The denial is upheld

This patient was diagnosed with an anxiety disorder. He reportedly was taking brand name Xanax for years with better efficacy but his provider prescribed Xanax 1 mg 5 times per day and the insurer denied this. He also reportedly had taken Sertraline and had adverse effects of feeling sick. He reportedly tried generic Alprazolam and had less efficacy as it reportedly was disintegrating quickly. 
 
This reviewer agrees with the decision to deny coverage for brand Xanax 1 mg 5 times per day stating that the plan quantity limit was 4 pills per day. The plan also states that if the dosage limit for the medication is not effective than one can prescribe a higher dosage so the 4 mg was not as effective so 5 mg was prescribed but the plan allows only 4 tablets per day so taking 2 mg Xanax tablets 12 5 times per day would be cutting it in half and this quantity was allowed by the plan as although it is 5 mg per day it also is only 2 1/2 pills per day.  

According to FOCUS (The Lifelong Journal in Psychiatry): Anxiety Disorders Volume II Number 3, pages 346-357, it states that for patients with generalized anxiety disorder cognitive behavioral therapy, pharmacotherapy, and other psychotherapies were not only indicated but also have been shown to result in reduction of symptoms. The standard pharmacological treatment for generalized anxiety disorder and panic disorder is serotonin reuptake inhibitors and also benzodiazepines. This patient reportedly tried a serotonin reuptake inhibitor in Sertraline but had an adverse effect by feeling ill and also a benzodiazepine, the generic Alprazolam, which was not as efficacious as it dissolved quickly. He reportedly was doing better with anxiety with brand name Xanax but the 4 mg per day FDA [food and drug administration] approved maximum dosage was no longer reported to be as effective so the prescribed increased the brand name Xanax to 1 mg 5 times per day. The insurer reportedly did not dispute the dosage of 5 mg stating that if the maximum dosage is not as effective one can try a higher dose, but the quantity limit of 4 pills per day was the denial by the insurer. They stated that one could prescribe brand name Xanax 2 mg tablets 12 tablet 5 times per day which is equivalent to 5 mg per day of Xanax and is under the plan quantity limit. For a subset of patients, there are indications that specific psychotropic medications could have a greater likelihood of response and tolerability based on clinical characteristics such as psychiatric comorbidities, medical comorbidities that could be exacerbated by psychotropic medication side effects, or family member history of response to a particular psychotropic agent.  While these clinical characteristics might guide a clinician to select a particular type of first-line drug treatment, for many patients the best treatment match is not clear, and treatment decision making is a process of "trial and error." In this case this patient responded to brand name Xanax and had an improvement in his symptoms with brand Xanax as opposed to generic Xanax so I agree with the recommendation for brand name Xanax. The patient had a worse response to the generic medication. He responded best to the brand name Xanax and did not respond to the generic equivalent Alprazolam. This patient reportedly had a good clinical response to the brand name benzodiazepine Xanax and did not respond well to the generic equivalent Alprazolam. Thus, the formulary generic Alprazolam was not effective, and the brand name Xanax was more effective than the formulary generic Alprazolam.  However, he could receive the brand name Xanax and the 5 mg per day if using 2 mg brand name Xanax tablets at one half 5 times per day for a total of 5 mg. The insurer denied the quantity limit of 5 one mg Xanax brand name tablets 5 times per day only. As a result, the recommendation is to uphold the decision and deny coverage for brand name Xanax 1 mg tablets 5 tablets per day as prescribed. It did appear that the health care plan acted reasonably, with sound clinical judgment, and in the best interests of the patient then.  

The insurer's denial of coverage for Formulary Exception for Xanax is upheld. Medical Necessity is not substantiated.