Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder 

Treatment: Vyvanse 20 milligram (mg) capsules

The insurer denied coverage for Vyvanse 20 milligram (mg) capsules

The denial is overturned

This patient reportedly had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and reportedly had taken Vyvanse for a long time since diagnosed with ADHD. It was reported that the patient was diagnosed with ADHD several years ago. It was reported that the patient did not take Vyvanse during the pandemic but recently restarted it. It was reported that the patient had efficacy and no side effects when taking Vyvanse in the past prior to the pandemic so Vyvanse 20 milligrams (mg) per day was restarted.

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD. 

Vyvanse is considered a Food and Drug Administration (FDA) approved medication for ADHD for children and adolescents and adults and has a unique mechanism of action. Vyvanse (Lisdexamfetamine dimesylate) is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the formulary psychostimulants as it is a prodrug needing to be activated after ingestion. This medication gets activated after ingestion, so abuse potential is considered less than other psychostimulants. 

It was reported that the patient was always treated with Vyvanse since their ADHD diagnosis with reported efficacy and lack of side effects. It is medically necessary for this patient then to restart it after the pandemic, during which time the patient had stopped it. 

Vyvanse has a unique mechanism of action that is different from the other formulary medications, so it was considered a risk to try the patient on a different medication as the other formulary medications had different mechanisms of action and may not have had the same therapeutic effect and also could have had an increased risk of adverse effects. Also, Vyvanse is a pro drug so there is less chance of abuse potential. 

While the formulary drugs have not been tried, it was reported that the patient had always been treated with Vyvanse and had efficacy and no side effects.  It was not considered in the patient's best interest then to stop an FDA approved medication with a unique mechanism of action to try another medication. It is a risk to try the patient on a different medication as the other formulary medications have different mechanisms of action and may not have the same therapeutic effect and also could have had an increased risk of adverse effects. 

The requested drug is likely to be more effective than the other methylphenidate and amphetamine/dextroamphetamine medications on the preferred formulary list because Vyvanse has a unique mechanism of action. 

The formulary drugs are expected to cause adverse effects. 

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

The formulary drug is expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Vyvanse 20 milligram (mg) capsules to treat Attention Deficit Hyperactivity Disorder (ADHD) is reversed.