Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention-deficit hyperactivity disorder
Treatment: Formulary Exception for Vyvanse 50mg (milligram) Capsule
The insurer denied coverage for a Formulary Exception for Vyvanse 50mg Capsule.
The denial is upheld.

This patient has attention problems and depressive symptoms. The patient has a diagnoses of attention-deficit hyperactivity disorder (ADHD)-Inattentive presentation and Major Depressive Disorder. The patient reportedly had a past suicide attempt by overdose and a psychiatric hospitalization. The patient was taking Depakote and Latuda and Vyvanse 50 milligrams (mg) every day. It was reported that the patient tried Zoloft, Abilify, and Vyvanse (Lisdexamfetamine) 60mg for 6 weeks without sustained efficacy. 

The insurer denied coverage for Vyvanse 50mg per day stating that the patient did not try and fail the formulary preferred medications for ADHD including amphetamine/dextroamphetamine, dextroamphetamine, dexmethylphenidate, atomoxetine, guanfacine, methylphenidate extended release (ER), Dyanavel, Qelbree, or Zenzedi.

The reviewer agrees with the decision to deny coverage for Vyvanse 50mg per day for this patient as the medical records did not support that this was considered an appropriate treatment or that the patient tried and failed several preferred formulary medications. 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 (Lisdexamfetamine dimesylate) is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This patient tried and failed Vyvanse (Lisdexamfetamine) 60mg per day with a 6-week trial and it was reported that it was a therapeutic failure. Taking Vyvanse again at a lower dosage of 50mg per day is not considered an appropriate treatment. The patient tried Adderall with therapeutic failure but did not try any of the other preferred medications including in the methylphenidate class. Psychostimulants include Methylphenidate ER (brand name is Concerta) which is a pump osmotic release oral system (OROS) Methylphenidate using osmotic delivery system in which the tablet is coated with 22 % immediate release Methylphenidate for the initial dosing and the long duration component is delivered by osmotic pump that gradually releases Methylphenidate producing an ascending serum concentration to approximate a 3 times daily dosing schedule. This patient did not try any of the preferred medications that were methylphenidate products including dexmethylphenidate or methylphenidate ER which are Food and Drug Administration (FDA) approved to treat ADHD. The patient also did not take dextroamphetamine products preferred medications including dextroamphetamine, Zenzedi, or Dyanavel which are also FDA approved to treat ADHD. There was no specific documentation that there were contraindications, adverse effects, or lack of efficacy for these mentioned FDA approved preferred formulary medications to treat ADHD. As a result, the recommendation is to uphold the previous decision and deny coverage for Vyvanse 50mg capsules per day for ADHD treatment for this patient. The insurer acted reasonably and with sound medical judgment.

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 drug is not expected to be ineffective.

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

Denial for Request for Formulary Exception for Vyvanse 50mg Capsule to treat ADHD is upheld.