Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will findabbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Medicare law defines those drugs that are eligible to be covered under the prescription drug benefit.Medicare law specifically excludes coverage for any drug for which payment would be available underParts A or B of Medicare for that individual. Social Security Act, Section 1860D-2(e)(2)(B).Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapyfurnished to a beneficiary who has received an organ transplant, provided the beneficiary receiving the drugwas enrolled in Medicare Part A at the time of the organ transplant. 42 CFR Section 410.30; MedicareBenefit Policy Manual, Chapter 15, Section 50.5.1.Medicare Part B local policy states that prescription drugs used in immunosuppressive therapy are coveredif they are prescribed following a kidney transplant, the transplant met Medicare coverage criteria in effectwith respect to the facility being approved for a kidney transplant, the patient was enrolled in Medicare PartA at the time of the transplant, the patient is enrolled in Medicare Part B at the time the drugs are dispensedand the drugs are furnished on or after the date of discharge. Assuming criteria I, II and III are met, atransplant is considered a covered transplant for purposes of this Medicare policy whether payment for thetransplant was made by Medicare or another insurer. You can find this rule at Noridian HealthcareSolutions, LLC, Policy Article for Immunosuppressive Drugs (A52474) or CGS Administrators, LLC,Policy Article for Immunosuppressive Drugs (A52474).A Part D plan is permitted to use a number of different tools to manage its formulary. One of these tools isknown as prior authorization. This process requires an enrollee to obtain coverage approval for a drugbefore the drug is dispensed and covered by the plan. 70 Federal Register No. 18, issued January 28, 2005(Preamble to Final Rule).The Part D Plan can only cover drugs prescribed for a medically accepted indication. The Plan requiresprior approval (also called prior authorization) before covering some prescription drugs. If prior approval isnot obtained, the Plan may not cover the drug. Please refer to the Plan's Evidence of Coverage.Each drug on the Plan's formulary is assigned to a tier. Generally drugs in higher tiers have higher copaysthan drugs in lower tiers. The Part D Plan contract allows an enrollee to request an exception to the Plan'scost-sharing structure to pay less for a drug. This is called a tiering exception. The prescriber mustprovide medical reasons to support a tiering exception. The Plan cannot grant a tiering exception for anydrug in the specialty tier. The Plan cannot grant a tiering exception for a non-formulary drug being coveredunder an exception to the formulary. Please refer to the Plan's Evidence of Coverage.The Part D Plan can only cover drugs prescribed for a medically accepted indication. The Plan requiresprior approval (also called prior authorization) before covering some prescription drugs. If prior approval isnot obtained, the Plan may not cover the drug. Please refer to the Plan's Evidence of Coverage.