Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention-deficit hyperactivity disorder (ADHD).

Treatment is Mydayis 25 mg (milligrams) CPTP (cyclopentyl-triazolo-pyrimidine) 24 HR (hour).

The insurer denied coverage for Mydayis 25 mg CPTP (cyclopentyl-triazolo-pyrimidine) 24HR (hour).

The denial is overturned.

This is a male patient with the diagnoses of ADHD and Major Depressive Disorder-Severe-recurrent. He reportedly was stable and doing well with medications, Trintellix for depression and Mydayis for ADHD. It was reported that he was taking this for years but lost health insurance due to losing his job but then got health insurance but was unable to afford Mydayis so he stopped it. According to a note by the family medicine provider, it was reported that she recommended that he restart Mydayis to target ADHD symptoms again as it reportedly was effective for years in the past and his symptoms reportedly worsened when he stopped this medication. He reportedly had tried Amphetamine/Dextroamphetamine in the past prior to Mydayis.

This reviewer disagrees with the decision to deny coverage for Mydayis 25 mg CPTP 24 hour as this is an FDA (Food and Drug Administration) approved medication for ADHD and he reportedly was taking it for years and was stable and doing well in terms of ADHD symptoms. The FDA reportedly approved Mydayis for the treatment of ADHD in young adults and older. This patient had a reported diagnosis of ADHD- so this medication was considered appropriate treatment for this patient.  It also stated that there were 3 randomized double-blind placebo-controlled studies in children and adults and it established efficacy in the treatment of ADHD. Mydayis reportedly is a mixed salt with a mixture of 3:1 dextro to levo amphetamine. It comes in dosages of 12.5, 25, 37.5, and 50.  It has 3 types of drug releasing beads with one intermediate and 2 different delayed release beads. It reportedly reaches peak plasma levels in 8 hours for adults and 7-10 hours in pediatric patients. A steady state reportedly is achieved in 7-8 days.  It is advantageous for longer duration of time coverage, and it is dispensed once per day. The medical records provided for review did report that the patient tried amphetamine/dextroamphetamine medication which was not effective. It was reported that he reportedly was taking Mydayis and was stable and doing well. He reportedly was doing well with this medication to treat ADHD symptoms until he lost health insurance due to losing his job and then he obtained other health insurance but could not afford the out-of-pocket costs and was doing worse. Mydayis is unique in that it has coverage that could last up to 16 hours, so it was considered more beneficial than other formulary medications that did not have this duration of coverage for this patient. Also, since he had a good response and had no reported major side effects to Mydayis, it was considered to be more effective for this patient than formulary medications as he might not have had the same efficacy to formulary medications or had as long of a coverage period which was 24 hours, and it was possible that he could have had side effects to other formulary medications but he did not have any to Mydayis. He was taking this effectively without major side effects for years, so it was considered in his best interest to take this again. It was possible that a formulary medication might not have been as effective and could have resulted in side effects, but Mydayis was documented for years as being effective and without major side effects. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for Formulary Exception for the drug Mydayis 25 mg CPTP 24HR is overturned.