Diagnosis: Type 2 Diabetes.
Treatment: Invokana.
The insurer denied Invokana.
The denial is overturned.

The patient is an adult male with type 2 diabetes. The request for continuation of Invokana is under review. The prior request was denied, as approval requires and failure of the two formulary alternatives, Farxiga and Invokana. The attending physician is appealing this determination. The appeal letter indicates that the patient has tried and failed Jardiance, and that the patient has tried and failed samples of Farxiga. The patient is currently stable on Invokana.

Yes, the health plan should cover the formulary exception for Invokana.

This patient has type 2 diabetes. He is stable on Invokana. He has tried and failed Jardiance. He has tried and failed samples of Farxiga, so he can be expected to fail a prescription of Farxiga as well. Without Invokana, this patient will be at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the formulary exception for Invokana.