Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Formulary exception for Vyvanse 30mg OR CAPS, Pre-service
The insurer denied the Formulary exception for Vyvanse 30mg OR CAPS, Pre-service.
The denial is overturned. 

The patient is a adult male. He is diagnosed with attention deficit hyperactivity disorder (ADHD). No comorbid psychiatric disorders are reported and the patient does not have a substance use disorder or general medical condition that is a focus of treatment. The patient has been prescribed Vyvanse 30 mg (milligrams) daily for several years with improved symptoms and functioning. The patient's prescribing clinician, a psychiatrist, is requesting coverage for continued treatment with Vyvanse for the treatment of ADHD (attention deficit hyperactivity disorder). The patient was not previously treated with formulary alternatives: generic formulations of Adderall XR (extended release), Strattera, Concerta, and Metadate. Vyvanse was reportedly removed from the formulary according to the patient's prescribing physician.

The health plan denied coverage for continued use of Vyvanse indicating that Vyvanse is non-formulary. The health plan suggests treatment with one of the formulary alternatives that include generic formulations of Adderall XR (extended release), Strattera, Concerta, and Metadate. The health plan requires that formulary drugs must be tried and failed before authorization for a coverage exception for Vyvanse. The denial and coverage determination were reviewed by the health plan's pharmacy director, who is a family medicine clinician.

Yes, the health plan should cover the formulary exception for Vyvanse 30 mg (milligrams) for the continued treatment of ADHD (attention deficit hyperactivity disorder).
The service provided is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-based treatment. The requested services/treatment being provided in this case is clinically appropriate, and is backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case.

Vyvanse at a daily dosage of 20-70 mg (milligrams) daily for the treatment of attention deficit hyperactivity disorder (ADHD) is reasonable (30 mg [milligrams] daily dose in this case), in the patient's best interest, and consistent with prevailing standards of medical practice, as well as the FDA (United States Food and Drug Administration)-indicated use for the treatment of ADHD (attention deficit hyperactivity disorder). Specifically, in this case, the patient has been effectively prescribed the requested treatment with Vyvanse 30 mg (milligrams) daily for several years in order to address symptoms of ADHD (attention deficit hyperactivity disorder). Thus, it is in the patient's best interest to continue to receive this medication that the clinician had determined provides clear therapeutic benefit, especially with respect to daily and social and occupational functioning. The requested benefit with Vyvanse 30 mg (milligrams) daily is provided for the purpose of treating ADHD (attention deficit hyperactivity disorder), and is clinically appropriate and indicated. It is entirely consistent with nationally recognized scientific evidence and prevailing medical standards and clinical guidelines, referenced below. To switch this patient from a medication that is working and effective and well-tolerated is not in the best interest of the patient. There is no evidence that the formulary alternatives will be as effective for this patient. Moreover, taking the patient off a medication that is effective and tolerated would place this patient at risk or would be detrimental to this patient with a reasonable degree of medical certainty, as the prescribing physician asserts. Therefore, the health plan should continue to cover the requested treatment with Vyvanse.

The requested benefit of Vyvanse at a dosage range of 20-70 mg (milligrams) should be approved for 12 months, or 36 months if allowed under the plan, as the medication at the requested daily dosage of 30 mg (milligrams) is being prescribed for a chronic condition that will require ongoing maintenance therapy in keeping with published guidelines, referenced below, and in keeping with prevailing standards of medical practice.

This answer is in keeping with NY (New York) State instruction for this review.