Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to provide reimbursement for Allopurinol 300 mg, Atorvastatin 40 mg, Ciprofloxacin 250 mg and 500 mg, Finasteride 5 mg, Fluticasone Furomate 100 mcg (Breo Ellipta), Hydrochlorothiazide 25 mg, Isosorbide Mono 60 mg, Losartan 25 mg, Sotalol HCL 80 mg, Tamsulosin 0.4 mg, Docusate Sodium Liquid 50 mg/5 ml and Magnesium Oxide 400 mg received while a patient at the hospital on February 16, 2019 through February 18, 2019. The Plan did not grant this request. We received this case to conduct an independent review.The 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 on February 16, 2019 through February 18, 2019. In this case, the records shows that you were a patient at the hospital on February 16, 2019 through February 18, 2019. You received Allopurinol 300 mg, Atorvastatin 40 mg, Ciprofloxacin 250 mg and 500 mg, Finasteride 5 mg, Fluticasone Furomate 100 mcg (Breo Ellipta), Hydrochlorothiazide 25 mg, Isosorbide Mono 60 mg, Losartan 25 mg, Sotalol HCL 80 mg. and Tamsulosin 0.4 mg. You submitted a request for reimbursement with a copy of the hospital bill. The Plan denied the reimbursement request on the basis that no proof of payment was provided. The Plan's denial letter stated that once payment had been made, the Plan would process the request for reimbursement. Your request to MAXIMUS included proof of payment in full for the self-administered drug portion of the bill. The Plan's out-of-network coverage rules have now been met. Therefore, our decision is the Plan is required to process and provide applicable reimbursement for Allopurinol 300 mg, Atorvastatin 40 mg, Ciprofloxacin 250 mg and 500 mg, Finasteride 5 mg, Fluticasone Furomate 100 mcg (Breo Ellipta), Hydrochlorothiazide 25 mg, Isosorbide Mono 60 mg, Losartan 25 mg, Sotalol HCL 80 mg. and Tamsulosin 0.4 mg, received while a patient at the hospital on February 16, 2019 through February 18, 2019.Docusate Sodium Liquid and Magnesium Oxide: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, Docusate Sodium Liquid 50 mg/5 ml and Magnesium Oxide 400 mg received while a patient at the hospital on February 16, 2019 through February 18, 2019 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.Information in the case record indicates that you were a patient at the hospital when you received these drugs. As such, you were not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor were you 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.