Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.  You asked the Plan to cover Nitroglycerin, Acetaminophen, Aspirin, Amlodipine, Atorvastatin, Ezetimibe, Meloxicam, Metoprolol, Pantoprazole, Sertraline, Losartan, Diazepam, Diphenhydramine, Prasugrel and Isosorbide purchased on May 23, 2020 through May 25, 2020. The Plan did not grant this request. We received this case to conduct an independent review.   The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. If an enrollee must use an out-of-network pharmacy, the enrollee will generally have to pay the full cost when the prescription is filled. The enrollee can ask the Plan to reimburse their share of the cost. In this case, the record shows that you were a patient at the hospital from May 23, 2020 to May 25, 2020. You received Nitroglycerin, Acetaminophen, Aspirin, Amlodipine, Atorvastatin, Ezetimibe, Meloxicam, Metoprolol, Pantoprazole, Sertraline, Losartan, Diazepam, Diphenhydramine, Prasugrel and Isosorbide for a medical emergency or urgent care. You submitted a request for reimbursement with a copy of the hospital bill. The Plan denied the reimbursement request on the basis that proof of payment was not provided. The Plan's denial letter stated that once payment had been made, the Plan would process the request for reimbursement. The enrollee's reconsideration appeal request submitted in the auto forwarded case file included proof of payment in full of the self-administered drug portion of the bill. The Plan's criteria for out-of-network coverage have now been met. Therefore, our decision is the Plan is required to process the claim for Nitroglycerin, Amlodipine, Atorvastatin, Ezetimibe, Meloxicam, Metoprolol, Pantoprazole, Sertraline, Losartan, Diazepam, Diphenhydramine, Prasugrel and Iosorbide.   Information in the case record indicates that the enrollee was an outpatient at the hospital when they received these drugs. As such, the enrollee was 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. Since this was a one-time emergency stay, the Plan should provide an exception to their normal coverage rules.  You asked the Plan to cover Acetaminophen and Aspirin purchased on May 23, 2020 to May 25, 2020. The Part D Plan is not required to cover Acetaminophen and Aspirin purchased on May 23, 2020 to May 25, 2020 according to Medicare rules.  Medicare law excludes certain drugs from Part D coverage. Acetaminophen and Aspirin are two of those excluded drugs because they are OTC drugs. Medicare 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 drug is a non-prescription or OTC drug. Therefore, Acetaminophen and Aspirin is not eligible for Part D coverage, and the Plan is not required to cover it 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.