Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xalatan, Atacand, Crestor and Toprol XL. The Plan did not grant this request. We received this case to conduct an independent review.A written request for Reconsideration must be filed within 60 days from the date of the Plan's Redetermination Letter. This request was not filed within the required 60-day time limit. However, the case record reflects there is good cause for the late filing. Therefore the Reconsideration request is being processed.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Xalatan 0.005% ophthalmic drops. The drug is requested to treat bilateral primary open-angle glaucoma. The prescriber has not indicated why all alternatives required by the Plan (Latanoprost, Lumigan, Rocklatan and Vyzulta eye drops) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Toprol XL 50 mg. The drug is requested to treat hypertension. The prescriber has not indicated why all alternatives required by the Plan (Metoprolol Tartrate tablet, Atenolol tablet, Carvedilol tablet, and Bisoprolol Fumarate tablet) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Atacand 16 mg. The drug is requested to treat hypertension. The prescriber has not indicated why all alternatives required by the Plan (Lisinopril, Ramipril, Benazepril, Quinapril, and Enalapril) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Crestor 10 mg. The drug is requested to treat hyperlipidemia. The prescriber has not indicated why all alternatives required by the Plan (Atorvastatin, Lovastatin, Pravastatin, and Simvastatin) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Xalatan, Atacand, Crestor and Toprol XL.We are dismissing the request for Potassium Chloride ER, Hydrochlorothiazide and Proventil HFA. We received your letter asking for an appeal of the Plan's unfavorable determination for Potassium Chloride ER, Hydrochlorothiazide and Proventil HFA. Medicare rules do not allow us to review this case until you have completed the appeal process with the Plan. You may request a Reconsideration appeal with us after the Plan issues an unfavorable Redetermination. You may wish to submit this request to the Plan at this time.