Appeal type: Prescription Drug
Decision: Partially Favorable

We previously issued a partially favorable reconsideration decision. In this decision we found that the Plan was required to process and provide any applicable reimbursement for Lanoxin and Cincalcet HCL received while a patient on September 17, 2019 and September 18, 2019. The Plan then requested a reopening on the basis that there was an error in our first review. Specifically, the Plan stated that the specific National Drug Codes (NDCs) provided for Lanoxin had a marketing end date and therefore is not eligible for coverage under Medicare Part D. Additionally the Plan stated that Cincalcet should be covered under Medicare Part B rather than Medicare Part D. We reopened this case to address the Plan's argument.Cinacalcet HCL The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received Cinacalcet HCL 30 mg tablets while a patient at the hospital in September 2019. This was an emergency or urgent care situation. You requested reimbursement from the Part D Plan. The request includes proof of payment for the self-administered drug portion of the bill. The Plan's original case file stated that the request for Cinacalcet HCL on the basis that prior authorization was not approved. Because this was a hospital stay, you were not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor were they able to obtain prior authorization or off-formulary exception review. Upon reopening the Plan clarified that requested drug was denied because it appears to be eligible for coverage under Medicare Part B as part of the End Stage Renal Disease (ESRD) Prospective Payment System (PPS). In this case the hospital billed Cinacalcet as a self-administered drug and it has been paid in full by the enrollee as a self-administered drug. Since this was a one-time emergency stay and the enrollee has been billed for this medication as a self-administered drug, the Plan should provide an exception to their normal coverage rules.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Cinacalcet HCL 10 mg received while at the hospital from September 17, 2019 to September 18, 2019LanoxinWhile a patient from September 17, 2019 to September 18, 2019 you received Lanoxin, NDC 0173-0242-75. Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We checked FDA sources and determined that Lanoxin tablet, NDC 0173-0242-75, had a marketing end date of September 30, 2015. Since the NDC provided by the hospital had a marketing end date prior to the date it was received; Lanoxin tablet, NDC 0173-0242-75 is not eligible for coverage or reimbursement under Medicare Part D. Therefore, the Plan is not required to cover or provide reimbursement for Lanoxin received September 17, 2019 through September 18, 2019.Our decision for the remaining drugs has not changed and is included below.Loratadine, Nepro CarbSteady and MultivitaminMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Loratadine, Nepro CarbSteady and Multivitamin are not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for them under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.This decision modifies our previous Partially Favorable Decision.