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 provide reimbursement for Amitriptyline 10 mg, Atorvastatin 40 mg, Carvedilol 3.125 mg, Doxycycline 100 mg, Finasteride 5 mg, Fludrocortisone 0.1 mg, Gabapentin 300 mg and 600 mg, Hydroxychloroquine 200 mg, Lacosamide 50 mg, Levetiracetam 500 mg, Meloxicam 7.5 mg, Oxycodone-Acetaminophen 10-325 mg, Oxycodone CR 10 mg, Pantoprazole EC 40 mg, Tamsulosin CR 0.4 mg, Magnesium Citrate and Multivitamin-Mineral tablet received and Potassium Chloride 20 meq received. The Plan did not grant this request. We received this case to conduct an independent review.Amitriptyline, Atorvastatin, Carvedilol, Doxycycline, Finasteride, Fludrocortisone, Gabapentin, Hydroxychloroquine, Lacosamide, Levetiracetam, Meloxicam, Oxycodone-Acetaminophen, Oxycodone CR, Pantoprazole EC and Tamsulosin CR and Potassium ChlorideThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received several self-administered drugs. You requested reimbursement from the Part D Plan. The Plan did not process the request. The documentation includes itemized statements for Amitriptyline 10 mg, Atorvastatin 40 mg, Carvedilol 3.125 mg, Doxycycline 100 mg, Finasteride 5 mg, Fludrocortisone 0.1 mg, Gabapentin 300 mg and 600 mg, Hydroxychloroquine 200 mg, Lacosamide 50 mg, Levetiracetam 500 mg, Meloxicam 7.5 mg, Oxycodone-Acetaminophen 10-325 mg, Oxycodone CR 10 mg, Pantoprazole EC 40 mg and Tamsulosin CR 0.4 mg received and Potassium Chloride 20 meq received. The record includes proof of payment for these Part D eligible drugs. The Plan has not yet processed these claims and the Plan has not provided any reason why these claims should not be processed at this time. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Amitriptyline 10 mg, Atorvastatin 40 mg, Carvedilol 3.125 mg, Doxycycline 100 mg, Finasteride 5 mg, Fludrocortisone 0.1 mg, Gabapentin 300 mg and 600 mg, Hydroxychloroquine 200 mg, Lacosamide 50 mg, Levetiracetam 500 mg, Meloxicam 7.5 mg, Oxycodone-Acetaminophen 10-325 mg, Oxycodone CR 10 mg, Pantoprazole EC 40 mg and Tamsulosin CR 0.4 mg received and Potassium Chloride 20 meq.Magnesium Citrate and Multivitamin-MineralMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Magnesium Citrate and Multivitamin-Mineral tablet received 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.Please note: the itemized statement submitted with the file indicates you received drugs other than the ones addressed in this letter. The Plan did not provide any documentation that they were untimely in making a decision for any other drug or date of service, other than those addressed in this letter. If you believe there are drugs not addressed in this letter that should be a part of this appeal, you may wish to contact the part D Plan directly.