Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Aloxi, Emend, Famotidine, and Cyramza. The Plan did not grant this request. We received this case to conduct an independent review.Our decision is that the Plan is required to cover Aloxi, Emend, and Famotidine.Regarding the request for Aloxi and Emend: Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. In this case, the Plan denied coverage for Aloxi and Emend because they are to be administered via an infusion pump. However, Aloxi (Palonosetron) and Emend (Fosaprepitant) do not appear to be eligible for Part B coverage as they are not named in the Medicare rules. We therefore asked our Physician Reviewer to determine if Part D coverage criteria have been met for Aloxi and Emend.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Aloxi 0.25 mg/5 mL and Emend 150 mg. Aloxi 0.25 mg/5 mL and Emend 150 mg are requested for treatment of chemotherapy-induced nausea and vomiting. Upon reconsideration, the prescribing physician states that the enrollee has tried and failed treatment with Zofran and Phenergan. The prescriber states why all alternatives required by the Plan (1) would not be as effective for the enrollee as the requested drug; and/or (2) would have adverse effects for the enrollee. Our Physician Reviewer's opinion is that formulary exception criteria are met for Aloxi and Emend.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore, the Plan is required to cover Aloxi and Emend.Regarding the request for Famotidine: We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Famotidine 20 mg/2 mL every 14 days.The drug is requested for prevention of gastric ulcers related to chemotherapy. 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:Effective in preventing stress-induced ulcers in both adult and pediatric patients.Therefore, the requested drug is being prescribed for a medically accepted indication.Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the formulary alternatives. The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary.Our Physician Reviewer's opinion is that formulary exception criteria are met for Famotidine.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore, the Plan is required to cover Famotidine.However, we have also decided that the Plan is not required to cover Cyramza.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 the rental or purchase of DME if the equipment is used in the patient's home or in an institution that is used as a home. Payment may be made for supplies necessary for the effective use of DME, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the DME. Medicare Part B local policy states that an external infusion pump is covered for administration of chemotherapy of the treatment of colorectal cancer.In this case, Cyramza is being administered via external infusion pump in the home, and is being used for colorectal cancer. This diagnosis is eligible for coverage under Medicare Part B. Thus, Cyramza as prescribed and administered in this case appears to be eligible for Part B coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, our decision is the Part D Plan is not required to cover Cyramza.This decision does not concern the medical necessity or appropriateness of Cyramza. It only establishes if payment can be made under the Medicare Part D benefit.You may wish to submit the request for Cyramza to the Medicare Part B carrier.