Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Triamcin-A/D/E compound lotion. The Plan did not grant this request. We received this case to conduct an independent review.Initially, the Plan denied the request for coverage for Triamcin-A/D/E compound lotion because a valid NDC was not provided for each ingredient at the time of the Redetermination. On Reconsideration, the enrollee provided a valid NDC for the Triamcinolone Acetonide ingredient and stated that the A/D/E lotion has no NDC. We called the pharmacy and spoke to a representative, who provided the same NDC for the Triamcinolone Acetonide cream and verified that the A/D/E lotion ingredient was used as a base. The NDC provided indicates that the Triamcinolone Acetonide 0.1% cream is not sourced by bulk powders, is approved by the FDA for both safety and efficacy and is not otherwise excluded from Part D coverage.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Triamcinolone Acetonide 0.1% cream, 120gm per 30 days. The drug is requested to treat Eczema. 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 Plan limits the amount of the drug to 450 gm per 30 days. The requested quantity is within the number of doses allowed by the Plan. Our Physician Reviewer's opinion is that quantity limit criteria are met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs. Based on a review of the available documentation, our Physician Reviewer's opinion is that the dose requested is within the allowed quantity limit. Therefore, the Plan is required to cover the requested quantity of Triamcinolone Acetonide 0.1% cream that is used in this Triamcin-A/D/E compound lotion.You asked the Plan to cover the A/D/E lotion used in the Triamcin-A/D/E compound prescription. The Plan did not grant this request. We received this case to conduct an independent review.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. If a drug is not used for a medically accepted indication of therapeutic value on the body, it cannot satisfy the definition of a Part D drug. A/D/E lotion is used as a base in the reconstitution of the Triamcin-A/D/E compound lotion. The use of A/D/E lotion in this instance is not therapeutic. Thus, A/D/E lotion does not meet the definition of a Part D drug. Therefore, the Plan is not required to cover the A/D/E lotion ingredient of the requested compound drug.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.