Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Albuterol. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Albuterol 2.5 mg/3 mL. The drug is requested to treat acute bronchitis. For coverage under theprescription drug benefit, Medicare requires that the drug prescribed be used for a medically acceptedindication. Our Physician Reviewer found that the Medicare-approved resources do contain citations tosupport the use of the requested drug for treatment of the noted condition. The following citation inDrugDex, a Medicare approved compendium, supports the use of the requested drug for the enrollee'scondition: Inhaled or oral broxaterol has been similar in efficacy to inhaled or oral albuterol in patientswith bronchitis. Therefore, the requested drug is being prescribed for a medically accepted indication. Therequested drug is not eligible for coverage under Medicare Part B. The enrollee satisfies the Plan's coveragecriteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare law specifically excludes coverage for any drug for which payment would be available under PartA or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for theeffective use of durable medical equipment, including drugs and biologicals which must be put directly intothe equipment in order to achieve the therapeutic benefit of the durable medical equipment. Medicare PartB local policy states that a small volume nebulizer and related compressor are covered when medicallynecessary to administer Albuterol for the management of obstructive pulmonary disease. In this case,Albuterol is administered to treat ICD-10 J20.9 (acute bronchitis, unspecified) which is not a Part B eligiblediagnosis. Therefore, it is not eligible for coverage under Medicare Part B and we sent the request to ourphysician reviewer to review for coverage under Medicare Part D.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewedthis file and determined that there are citations in the Medicare approved compendia that support the use ofAlbuterol for the diagnosed condition. As a result, Albuterol is being prescribed for a medically acceptedindication 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 aremet. Therefore, our decision is the Plan is required to cover Albuterol.We are dismissing the request for Ipratropium. We received your letter asking for an appeal of the Plan'sunfavorable determination for Ipratropium. Medicare rules do not allow us to review this case until youhave completed the appeal process with the Plan. You may request a Reconsideration appeal with us afterthe Plan issues an unfavorable Redetermination. You may wish to submit this request to the Plan at thistime.