Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Methadone HCL, 5 mg tablet, 60 per 30 days. 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 Methadone HCL, 5 mg tablet.The drug is requested to treat chronic pain due to spinal arthritis. 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 prescriber was asked to address the Plan's prior authorization criteria. The prescriber responded by stating that:1) The patient's pain is severe enough to require daily, around-the-clock, long-term opioid treatment. 2) The patient is not opioid naive. 3) Non-opioid therapies have been optimized and are being used in conjunction with opioid therapy. 4) The prescriber states they have checked the patient's history of controlled substance prescriptions using the state prescription drug monitoring program (PDMP). 5) The prescriber attests that they have discussed risks (eg, addiction, overdose) and realistic benefits of opioid therapy with the patient. 6) The prescriber states that there a treatment plan (including goals for pain and function) in place. 7) The prescriber states that reassessments are scheduled at regular intervals. (every 2 months) 8) The prescriber states that the requested medication is being prescribed for intractable pain (ie, FDA labeled use).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 Methadone HCL, 5 mg tablet, 60 per 30 days for the diagnosed condition. As a result, Methadone HCL, 5 mg tablet, 60 per 30 days 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 Methadone HCL, 5 mg tablet, 60 per 30 days.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.