Diagnosis: Opioid dependence
Issue under review: Formulary exception for Lucemyra

Determination:
The health plan should not cover the Formulary exception for Lucemyra.

The case involves a young adult male with a diagnosis of opioid dependence with withdrawal (F11.23). The health plan received a request for authorization for treatment with Lucemyra (lofexidine) tabs.

The health plan has denied authorization for the requested medication which is a formulary exception. Alternative treatments are available and have not been clearly tried and failed in order to approve a formulary exception.

Formulary alternatives are available to address the patient's opioid use disorder and opioid withdrawal symptoms. There is no evidence that the requested medication, Lucemyra, is more beneficial than formulary alternatives that include buprenorphine and clonidine used as clinically appropriate. Thus, based on the submitted information, the requested formulary exception for Lucemyra is not reasonable in this case scenario and should not be covered for this patient.

This answer is consistent with the guidelines and scientific literature, referenced below, and consistent with the instructions for this mandated NY State Review.