Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder

Treatment: Adderall XR (extended release) (amphetamine-dextroamphetamine ER (extended release))

The insurer denied coverage for Adderall XR (extended release) (amphetamine-dextroamphetamine ER (extended release))

The denial is overturned

This patient reportedly has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)-unspecified type and was prescribed Adderall extended release (XR) 60 milligram (mg) brand name per day and also had supplementation with Adderall immediate release (IR) generic to target ADHD symptoms. It was reported that the patient had been taking the generic Adderall IR since 2014 and the brand Adderall XR since 2016 with reported efficacy. It was reported by the provider that this combination worked incredibly for the patient. The patient also reportedly had a mood disorder and was taking Wellbutrin, Carbamazepine, as well as Guanfacine in addition to the brand name Adderall XR 60 mg and the generic Adderall IR to target ADHD symptoms. It was reported that the patient has been taking this medication combination for years with reported efficacy and tolerability. The provider reportedly ordered Adderall XR 30 mg tablets # 60.
  
The medical records provided enough specific evidence to support that this patient required this medication then. This patient did have documentation of having a diagnosis of ADHD and Adderall XR is a Food and Drug Administration (FDA) approved medication to treat ADHD. According to the American Academy of Child and Adolescent Psychiatry's (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with ADHD it reports that short term efficacy of psychopharmacological interventions for ADHD were well established. It also reports that stimulants were considered highly efficacious in the treatment of ADHD with up to 75 percent (%) clinical responders. Some patients respond to certain psychostimulants and not others. The psychostimulants include Methylphenidate products, amphetamine/dextroamphetamine products which include Adderall, Vyvanse (Lisdexamfetamine dimesylate), and Strattera (Atomoxetine) which is a norepinephrine reuptake inhibitor. Adderall is a psychostimulant in the amphetamine/dextroamphetamine class and is FDA approved for ADHD in people 6 years old and older. Adderall XR reportedly was FDA approved for ADHD in children and adolescents in 2001 and in 2004 Adderall XR was the first stimulant approved for ADHD in adults in 2004. Adderall is the brand name and amphetamine/dextroamphetamine is the generic equivalent. Both are FDA approved medications, and it was reported that the patient had a diagnosis of ADHD, and this is a diagnosis that is diagnosed in adults now as well as children. The maximum reported FDA approved recommended dosage for Adderall XR for adults is 60 mg per day so the 30 mg of Adderall XR brand name # 60 at two per day was within the FDA approved and recommended maximum dosage for adults.  It was reported that the patient was taking these medications for years with efficacy and tolerability, so it was considered necessary treatment and in the patient's best interest to continue taking this FDA approved medication to treat their ADHD symptoms. 

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 non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Adderall XR (amphetamine-dextroamphetamine ER) is reversed.