Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Ibrance . 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 Ibrance 125 mg. The drug is requested to treat breast cancer in combination with Letrozole and Faslodex, which is an off-label (non-FDA approved) use. The enrollee is a 66 year old woman with metastatic breast cancer involving bones. Her cancer is estrogen receptor positive and HER2 negative. She has been treated in the past with Ibrance. She has been treated with Doxil. No other information about past treatments was submitted for review. The prescriber requests Ibrance to be given with Letrozole and Faslodex to treat her.Ibrance is indicated to be used with an aromatase inhibitor (AI) such as Letrozole as first line endocrine therapy for hormone receptor positive, HER2 negative breast cancer. It is also indicated to be used with Faslodex as subsequent therapy for the same type of breast cancer. It is not supported to be used with both and AI and Faslodex. Also, there is no information regarding whether she had progressive cancer on previous Ibrance.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 Ibrance 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 Ibrance. 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.