Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder (ADHD)-inattentive type
Treatment: Formulary exception for Concerta
The insurer denied: Formulary exception for Concerta
The denial is overturned.

The patient is an adult female. She is diagnosed with attention deficit hyperactivity disorder (ADHD)-inattentive type. The patient has been prescribed brand Concerta (methylphenidate extended-release tablet) at a dosage of 54 milligrams daily. The patient failed to respond to generic Adderall and Vyvanse, as well as generic extended-release methylphenidate due to adverse effects, prompting the switch to brand Concerta, with a 
subsequent positive therapeutic result with tolerability and improved functioning. The health plan has denied coverage of the requested brand Concerta (methylphenidate extended-release formulation) due to prior authorization criteria and the requirement that the patient must have tried and failed at least three formulary alternatives to allow a coverage exception (step therapy). Formulary alternatives include amphetamine-dextroamphetamine extended release (generic Adderall extended release), dexmethylphenidate extended release (generic Focalin), methylphenidate extended release (generic Concerta or Ritalin extended release), generic Dexedrine, and Azstarys. The prescribing physician is requesting coverage for treatment with the brand Concerta at the effective dose of 54 milligrams daily for the treatment of ADHD (attention deficit hyperactivity disorder) in view of the treatment failure with generic Concerta and Vyvanse and Adderall. The appeal indicates that everyone is better served to stay the course with a medication that is known to be effective and well tolerated with a positive therapeutic result addressing impairment of functioning due to symptoms of ADHD (attention deficit hyperactivity disorder).

The health plan should cover the formulary exception for Concerta.

As asserted in the appeal, the prescribing physician reasonably argues that this patient is better served to stay the course with the non-formulary medication that is known to be effective and 
well tolerated with a positive therapeutic result addressing the functional impairments and symptoms of ADHD (attention deficit hyperactivity disorder). In this case, the patient would be harmed if Concerta is discontinued or switched to another formulary alternative that is not known to be effective and would pose risk for adverse effects. Specifically, in this case, the requested benefit with band Concerta (methylphenidate extended-release tab) at an effective dose of 54 milligrams daily is provided for the purpose of treating ADHD (attention deficit hyperactivity disorder), as clinically appropriate and indicated; and is entirely consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines, referenced below. Methylphenidate extended-release at a daily dosage of 54 milligrams tabs daily for the treatment of attention deficit hyperactivity disorder (ADHD) is reasonable, in the patient's best interest, and is provided with sound medical judgment. Moreover, the use of Brand Concerta (methylphenidate extended-release formulation) is more likely to have a positive therapeutic effect than the remaining medications on the health plan formulary, especially in view of the clinical history of a positive therapeutic result noted in the submitted records and documentation. This answer is in keeping with published guidelines and scientific literature, referenced below, 
and in keeping with prevailing standards of medical practice for the treatment of the condition diagnosed in this case.