Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover and provide tiering exception for Tamsulosin HCL, Finasteride and Eliquis.The Plan did not grant this request. We received this case to conduct an independent review.Tamsulosin:We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Tamsulosin 0.4 mg. The drug is requested to treat malignant neoplasm of prostate and elevated prostatespecific antigen, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do notcontain any citations to support the use of the requested drug, as prescribed, for treatment of the notedcondition. Therefore, the requested drug is not being prescribed for a medically accepted indication asdefined by Medicare law. As such, an exceptions request based on medical necessity cannot be consideredbecause the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.Finasteride:We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Finasteride 5 mg. The drug is requested to treat malignant neoplasm of prostateand elevated prostate specific antigen. The drug is on Tier 2 of the Plan's formulary. There are no availablelower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligiblefor a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Eliquis:We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Eliquis 5 mg. The drug is requested for use as a blood thinner. The drug is onTier 3 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treatthe enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer'sopinion is that tiering exception criteria are not met.Tamsulosin: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 reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Tamsulosin HCL for the diagnosed condition. As a result, thedrug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, itcannot be covered under the Medicare Part D benefit for this condition. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forTamsulosin HCL.Please note: the request for a tiering exception (lower copayment) for Tamsulosin HCL was not reviewed.We cannot consider a tiering exception for a drug for which the Part D Plan is unable to provide coverage.Finasteride and Eliquis:Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere 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 Finasteride and Eliquis.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.