Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Major Depressive Disorder
Treatment: Formulary Exception for Vilazodone to treat depressive symptoms
The insurer denied coverage for Formulary Exception for Vilazodone to treat depressive symptoms
The denial is upheld.

This patient had diagnoses of Major Depressive Disorder-single episode-moderate, attention deficit hyperactivity disorder (ADHD)-predominantly inattentive presentation, and Generalized Anxiety Disorder. He had seen his psychiatrist, who prescribed Vilazodone 20 milligram (mg) to target depressive symptoms and Adderall extended-release (XR) 10 mg and Adderall immediate-release (IR) 5 mg for ADHD symptoms. It was reported that he had a trial of other medications which did not work but there were no documented specific medications with dosages and durations documented in the medical records provided for review.
  
The reviewer agrees with the decision to deny coverage for Vilazodone 20 mg per day as this reportedly was a nonformulary medication and needed prior authorization criteria met. The prior authorization criteria were for documentation that he tried or failed formulary medications including citalopram, escitalopram, fluoxetine, paroxetine, sertraline, or Trintellix; or documentation that the formulary medications were ineffective, or he had adverse effects, or there was a contraindication. There was no documentation for review in the records provided stating specific medications with dosages and durations tried. 

There were no medical records giving specific evidence as to why the patient could only be treated with the antidepressant Vilazodone (Viibryd) for the treatment of major depressive disorder. There was no specific evidence stating that the patient was taking this medication for a lengthy period of time and had notable efficacy which would support staying with this medication instead of switching to another antidepressant medication that was on the formulary, as he reportedly started it recently. Also, there was no specific documentation in the medical records for review stating that he tried and failed any of the formulary medications with an adequate dosage or duration of trial, or that he tried and had an adverse effect to any formulary medications, or that there was a contraindication to trying any formulary medications. 

The American Psychiatric Association Practice Guideline for the Treatment of Patients with Major Depressive Disorders reports that pharmacotherapy with antidepressant medications are considered first line treatment for depression. Many randomized trials have found that various antidepressants have similar effectiveness overall, but drugs might not be equally effective for an individual patient. Although Vilazodone (Viibryd) was considered an appropriate treatment for major depressive disorder for this patient and is an FDA (Food and Drug Administration) approved medication for the treatment of major depressive disorder, which this patient had as a diagnosis, the medical records for review lacked specific documentation of specific failed trials of formulary medications, adverse effects to formulary medications, or contraindication to formulary medications. 
  
The formulary drugs are not expected to cause adverse effects. 

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

The formulary drugs are not expected to be ineffective.

The non-formulary drug is not expected to be more effective that the formulary alternatives.

The insurer's denial of coverage for Formulary Exception for Vilazodone to treat depressive symptoms is upheld.