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202101-134093

2021

Healthfirst Inc.

Medicaid

Blood Disorder, Endocrine/ Metabolic/ Nutritional

Pharmacy/ Prescription Drugs

Formulary Exception

Overturned

Case Summary

Diagnosis: Hypercholesterolemia.

Treatment: Formulary Exception for Lipitor 40 milligrams (mg).

The insurer denied coverage for the Formulary Exception for Lipitor 40 mg.

The denial is overturned.

This is a female patient with hypercholesterolemia treated with Lipitor 40 milligrams (mg) daily. Her physician provided documentation that the patient has tried several formulations of statin medications. The patient has tried all other formulary statin medications and in each case adverse reactions were noted.

Several studies have been published evaluating the comparative efficacy of generic vs name brand drugs. In this case there is no difference in efficacy between Lipitor vs Atorvastatin. However, in this case the patient appears to have a demonstrable difference in cholesterol levels when on Lipitor as compared to generic alternatives. Her physician documents adverse side effects to the generic formulations on the formulary. Studies have demonstrated that a small number of individuals require reversion to name brand medications following switchover to generic formulations. In this case the patient should be prescribed Lipitor given adverse reactions. The requested drug is, for this patient, more effective than the formulary alternatives.

The carrier's denial of the request for Formulary Exception for Lipitor 40 mg is overturned.

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