Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Testosterone Enanthate 1000 mg/5 mL. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).In this case, the record reflects that Testosterone Enanthate will administered in the enrollee's home and not supplied from physican stock incident to the service of a physician. As a result, the drug as administered in this case does not appear to be eligible for coverage under Medicare Part B. Therefore, we asked our Physician Reviewer to review coverage under Part D.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Testosterone Enanthate 1000 mg/5 mL, 200 mg every 2 weeks. The drug is requested to treat male hypogonadism with panhypopituitarism and benign neoplasm of pituitary gland. Upon reconsideration, the prescribing physician has submitted chart notes which support that the enrollee has a diagnosis of male hypogonadism and panhypopituitarism with pituitary tumor treated with surgery and radiation therapy. 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. The following citation in DrugDex, a Medicare approved compendium, supports the use of the requested drug for the enrollee's condition: Testosterone enanthate is indicated for testosterone replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Therefore, the requested drug is being prescribed for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part B. 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 Testosterone Enanthate for the diagnosed condition. As a result, Testosterone Enanthate 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 Testosterone Enanthate.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.