The patient is diagnosed with bipolar I disorder with a history of recurrent episodes of depression. The patient has been effectively treated with Vraylar (cariprazine) 1.5 milligrams (mg) daily since 2017 with tolerability and partial remission of symptoms.
Other prescribed medications include Lamictal, Cymbalta and as needed (PRN) use of low-dose Xanax. The patient had previously failed to benefit from treatment with aripiprazole, olanzapine, quetiapine and risperidone due to lack of clinical response or tolerability issues including the development of cardio-metabolic side effects (weight gain) and/or akathisia. The health plan's determination of medical necessity is overturned in whole. In this case, the requested benefit of Vraylar is clinically indicated and appropriate in keeping with prevailing standards of medical practice. The patient has reportedly failed several trials of alternative formulary medications without benefit or with adverse effects resulting in discontinuation of treatment. Vraylar has been providing reasonable clinical benefit since 2017. The use of Vraylar for the treatment of bipolar disorder is also consistent with product labeling and prevailing standards of medical practice.