Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Levothyroxine, 25 mcg tablet, 90/90, and a tiering exception for Levothyroxine, 25 mcg tablet. 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 Levothyroxine, 25 mcg tablet. The drug is requested to treat hypothyroidism. There are no applicable utilization management criteria identified for coverage of the drug. Our Physician Reviewer's opinion is that Medicare Part D criteria for coverage of the requested drug have been met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Levothyroxine, 25 mcg tablet. The drug is requested to treat the enrollee's condition. The drug is a generic on tier 2 of the Plan's formulary. There are no available lower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Levothyroxine, 25 mcg tablet, 90/90 is on the Plan's formulary and is not subject to any of these restrictions. Therefore, our decision is the Plan is required to cover Levothyroxine, 25 mcg tablet, 90/90.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Levothyroxine, 25 mcg tablet.We are dismissing the request for Hydrocodone. We received your letter asking for an appeal of the Plan's unfavorable determination for Hydrocodone. 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.We are dismissing the request for Hydrocodone-Acetaminophen. The Plan has agreed to pay for Hydrocodone-Acetaminophen, so there is no need for a reconsideration review. Contact the Plan to learn more about how and when the Plan will pay for Hydrocodone-Acetaminophen.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.