Diagnosis: Rheumatoid arthritis.
Treatment: Formulary exception for Duexis
The insurer denied the Formulary exception for Duexis
The denial is overturned.

This patient is a female with history of rheumatoid arthritis. The patient has previously tried and failed ibuprofen, duloxetine, diclofenac and naproxen. She has been treated with Duexis with good clinical benefit. Duexis was initially denied due to the patient not having tried and failed at least three formulary alternatives including celecoxib, diclofenac, diflunisal, etodolac, ibuprofen, meloxicam, nabumetone, naproxen, oxaprozin or sulindac with lansoprazole, omeprazole, pantoprazole or Dexilant. The reason for the appeal is because the patient has been on Duexis and doing well.

Yes, the health plan should cover the proposed treatment.
It is not known if a formulary drug would be as effective as the requested drug Duexis. It is not known if the patient would have adverse effects to a formulary alternative. In addition, the patient has tried and failed three formulary non-steroidal anti-inflammatory drugs (NSAIDs) but documentation does not support that these have been tried and failed in combination with one of the formulary proton pump inhibitors (PPIs).

The patient has been on Duexis with good clinical benefit. Clinical studies do show that non-medical switching was more often associated with negative or neutral effects than positive effects on an array of important outcomes. Among patients with stable/well controlled disease, non-medical switching was associated with mostly negative effects. There are no clinical studies comparing formulary options to Duexis to indicate whether formulary alternatives would be more efficacious or safer than the current requested drug Duexis. It is not known if the patient will respond as well to a formulary alternative if she were to switch or if she would have worsening disease due to switching. It is known that the patient is stable and responding well to the requested drug Duexis and therefore the health plan should cover the proposed treatment.