Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Cymbalta DR, Cozaar, Lipitor, Catapres, Valium and Toprol XL. 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 Cymbalta DR 30 mg capsule. The drug is requested to treat fibromyalgia. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Cozaar 100 mg tablet. The drug is requested to treat hypertension. The prescriber has not indicated why all alternatives required by the Plan (ARBs (Olmesartan, candesartan, Eprosartan, Irbesartan, Losartan, Telmisartan, and Valsartan); and other blood pressure medications such as beta blockers (e.g., Labetalol, Metoprolol, Atenolol, Betaxolol, Bisoprolol, Bystolic, Propranolol), calcium channel blockers (e.g., Amlodipine, Diltiazem, Verapamil), Thiazide diuretics (e.g., Hydrochlorothiazide, Chlorthalidone), and ACEIs (e.g., Lisinopril, Enalapril, Ramipril), would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Lipitor 10 mg tablet. The drug is requested to treat hyperlipidemia. The prescriber has not indicated why all alternatives required by the Plan (Fenofibrate, Fenofibric acid, Gemfibrozil, Atorvastatin, Fluvastatin/ER, Lovastatin, Pravastatin, Rosuvastatin, Simvastatin, Cholestyramine, Colesevelam, Colestipol, Ezetimibe, Niacin ER, and Omega-3 ethyl esters (generic Lovaza)) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Catapres 0.1mg tablet. The drug is requested to treat hypertension. The prescriber has not indicated why all alternatives required by the Plan (beta blockers (e.g., Labetalol, Metoprolol, Atenolol, Betaxolol, Bisoprolol, Bystolic, Propranolol), calcium channel blockers (e.g., Amlodipine, Diltiazem, Verapamil),thiazide diuretics (e.g., Hydrochlorothiazide, Chlorthalidone), and ACEIs (e.g., Lisinopril, Enalapril, Ramipril)), would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Valium 10 mg tablet. The drug is requested to treat anxiety. The prescriber has not indicated why all alternatives required by the Plan (Buspirone, Alprazolam, Diazepam, Lorazepam, and Oxazepam) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Toprol XL 100 mg tablet. The drug is requested to treat hypertension. The prescriber has not indicated why all alternatives required by the Plan (carvedilol, carvedilol ER (an authorized generic for brand Coreg CR is available), Labetalol, Metoprolol ER, Metoprolol, Atenolol, Betaxolol, Bisoprolol, Bystolic, Propranolol, Nadolol, Timolol, Enalapril, Lisinopril, Ramipril, Losartan, Valsartan, Olmesartan, Amlodipine, Diltiazem, Hydrochlorothiazide, and Chlorthalidone) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.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 not met. Therefore, the Plan is not required to cover Cymbalta DR, Cozaar, Lipitor, Catapres, Valium and Toprol XL.