Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Bipolar disorder

Treatment: Formulary Exception for Lamictal to treat Unspecified Bipolar Disorder

The insurer denied coverage for Formulary Exception for Lamictal to treat Unspecified Bipolar Disorder

The denial is overturned

This adult patient has a diagnosis of Unspecified Bipolar Disorder. The patient has past major depressive episodes and rapid cycling. The patient has a history of irritable, euphoric, and depressed mood, impulsivity, racing thoughts, increased and pressured speech, mood swings, depressive symptoms, and panic attacks as well as feeling overwhelmed. The patient has been in psychiatric treatment for several years. It was reported that the patient had a trial of Carbamazepine, and it was ineffective. The patient also took lamotrigine which is the generic form of Lamictal but had a lack of response. It also was reported that the patient took Lithium without reported efficacy. It was reported that the patient had rapid cycling until taking Lamictal and was stabilized. The treating psychiatrist stated that it was medically necessary for the patient to continue taking Lamictal as the patient was at risk of decompensation psychiatrically without this medication.

It was reported that this patient took Lamictal for many years with reported efficacy and tolerability. The patient had reports of rapid cycling bipolar disorder without Lamictal. According to Medscape News: Psychiatry and Mental Health-Managing Psychotropic Drug Costs: Will Formularies Work, many randomized trials have found that various psychotropic medications have similar effectiveness overall, but drugs might not be equally effective for an individual patient. It states that for a subset of patients, there are indications that specific psychotropic medications could have a greater likelihood of response and tolerability based on clinical characteristics such as psychiatric comorbidities, medical comorbidities that could be exacerbated by psychotropic medication side effects, or family member history of response to a particular psychotropic agent. While these clinical characteristics might guide a clinician to select a particular type of first-line drug treatment, for many patients the best treatment match is not clear and treatment decision making is a process of "trial and error."

In this case this patient responded to brand name Lamictal but did not respond to generic Lamictal (lamotrigine). The patient has been taking this brand name Lamictal for many years with efficacy and tolerability.

According to FOCUS The Journal of Lifelong Learning in Psychiatry-Bipolar Disorder 2011 Volume IX Number 4 it states that Lamictal is a bipolar antidepressant. In this case, this patient had efficacy as a bipolar antidepressant with the brand name Lamictal, so it was considered an appropriate treatment since the patient tried generic Lamictal (lamotrigine); one of the formulary medications and had lack of efficacy. The patient also tried another formulary medication, Carbamazepine, and it was also not effective. In addition, the patient tried another Food and Drug Administration (FDA) approved medication for bipolar disorder in Lithium with no reported efficacy and worsened reported depression. It would be considered risky and not in the best interests of the patient to switch to another mood stabilizer since Lamictal exhibited efficacy for years. The recommendation is to overturn the previous decision and approve brand name Lamictal for this patient.

The formulary drugs are not expected to cause adverse effects.

Although two of the formulary drugs were tried (carbamazepine and lamotrigine) the patient did not have an adverse reaction or contraindication, they were ineffective.

The formulary drugs are expected to be ineffective.

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

The carrier's denial of a request for a Formulary Exception for Lamictal to treat Unspecified Bipolar Disorder is overturned.