Diagnosis: Generalized Anxiety Disorder.
Treatment: Vilazodone.
The insurer denied: Vilazodone.
The denial is upheld.

The patient is a teenage female. She is diagnosed with generalized anxiety disorder (GAD), comorbid ADHD (attention deficit hyperactivity disorder)-inattentive type, and unspecified trauma and stressor related disorder. The patient is prescribed Viibryd at the starting or initial dose of 10 mg (milligrams) together with Wellbutrin XL (extended release) 150 mg (milligrams) daily. There is a history of treatment resistance or tolerability issues with fluoxetine. Moreover, several antidepressant medications were shown to pose a risk for gene-drug interactions, as indicated with pharmacogenomic testing.
The health plan denied coverage for Viibryd based on plan coverage criteria indicating that three formulary alternatives must be tried and failed or formulary alternative must be contraindicated before an exception is allowed. Suggested formulary alternatives include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and Trintellix. The prescribing clinician is requesting health plan coverage for Viibryd in view of the lack of a clinical response or tolerability issues with fluoxetine and genetic testing, which indicates a gene-drug interaction with several other antidepressant/anxiolytic medications, including the suggested formulary alternative, except for Trintellix, which is in the "use as directed" list along with multiple other formulary options, which include mirtazapine, trazodone, TCAs (tricyclic antidepressants), and SNRIs (serotonin-norepinephrine reuptake inhibitors).

The health plan should not cover the Formulary exception for Vilazodone in this case.

Alternative and remaining formulary antidepressant medications potentially available for treatment of GAD (generalized anxiety disorder) include the suggested formulary alternative of Trintellix, which is in the "use as directed" category with the genetic testing, as well as several of the suggested formulary alternatives that are in the "use with caution" category. There is no evidence that the formulary drugs had been ineffective for this patient or would not be as effective as the requested non-formulary drug or would have adverse effects for this patient. This includes information provided with pharmacogenomic testing. This answer is consistent with the scientific literature and published guideline, referenced below, as well as prevailing standards of medical practice and the instruction for this New York State review pertaining to formulary alternatives.