Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Afinitor. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Afinitor 10 mg; 28/28. The drug is requested to treat metastatic breast cancer never treated with a non-steroidal aromatase inhibitor and in combination with Exemestane, which is an off-label (non-FDA approved) use. The enrollee is a 50 year old woman with metastatic breast cancer involving bones, marrow and nodes. Her tumor was hormone receptor positive and HER2 negative. She was treated for stage IIIC breast cancer in 2013 with Doxorubicin, Cyclophosphamide, surgery, Paclitaxel and radiation and Tamoxifen. She relapsed in bones in 2018 with biopsy confirming hormone receptor positive status. She was treated with Palbociclib and Fulvestrant. She now has progression of the cancer in nodes. The prescriber requests Afinitor to be given with Exemestane to treat her.The prescriber cites the BOLERO-2 trial in support of the request. The BOLERO-2 trial required patients to have had progressive cancer on a non-steroidal aromatase inhibitor. These are Letrozole and Anastrozole. (N Engl J Med. 2012 Feb 9;366(6):520-9.) The enrollee has not been treated with either drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. For Part D drugs used in an anticancer chemotherapeutic regimen, a medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia or peer-reviewed medical literature in CMS-approved journals or publications.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia and there was no peer-reviewed literature from an approved journal submitted to support the use of Afinitor for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Afinitor. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.