Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Abiraterone Acetate, 250 mg tablet as prescribed. 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 Abiraterone Acetate, 250 mg tablet; 120/30.The drug is requested to treat prostate cancer. The enrollee is an 84 year old man with prostate cancer diagnosed. He has been treated with LHRH analogs and Casodex. He is currently receiving Eligard. His PSA rose from 4.2. The prescriber requests Abiraterone to be given with Prednisone to treat him. The prior authorization form indicated he would not be receiving an LHRH analog. The urology office note, clearly indicates he will be on Eligard which is an LHRH analog. A note indicates that the urologist is administering the Eligard while the Abiraterone is being prescribed at a cancer center.Per the FDA website, Abiraterone acetate is indicated in combination with prednisone for the treatment of patients with - Metastatic castration-resistant prostate cancer (CRPC). The enrollee has had progression on androgen deprivation therapy therefore he has castration resistant prostate cancer. He has rising PSA indicating metastasis. Therefore the enrollee meet the FDA indicated use.For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of the requested drug for treatment of the noted condition. Therefore, the requested drug is being prescribed for a medically accepted indication.The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. 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. Our Physician Reviewer reviewed this file and determined that there are citations in the Medicare approved compendia that support the use of Abiraterone Acetate, 250 mg tablet as prescribed for the diagnosed condition. As a result, Abiraterone Acetate, 250 mg tablet as prescribed is being prescribed for a medically accepted indication as defined by Medicare law.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Abiraterone Acetate, 250 mg tablet as prescribed.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.