Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover multiple self administered drugs, including: Tylenol, Sennosides-Docusate, Vitamin C, Polyethylene Glycol powder, Vitamin B-12, Allopurinol, and Oxycodone HCL which were provided to you while in the hospital. The Plan did not grant this request. We received this case to conduct an independent review.Regarding Allopurinol and Oxycodone HCL:Originally, the Plan denied the request for Allopurinol and Oxycodone HCL on the basis that the National Drug Codes (NDC) provided (62584-988-11 and 68084-354-11, respectively) are from discontinued and/or repacked NDCs. It is reasonable that a hospital would provide self-administered drugs that have been discontinued and/or repackaged. We checked our sources and confirmed that these particular NDCs for Allopurinol and Oxycodone are within their marketing end date, and they are not excluded for any other reason according to Medicare law.Because this was a hospital stay, you were not in a position to obtain 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. It is our decision that the Plan must process and provide any applicable reimbursement for Allopurinol and Oxycodone HCL provided during your hospital stay.Regarding Tylenol, Sennosides-Docusate, Vitamin C, Polyethylene Glycol powder, Vitamin B-12:Medicare law excludes certain drugs from Part D coverage. 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 Tylenol, Sennosides-Docusate, and Polyethylene Glycol power you received are classified as non-prescription or OTC (over-the-counter) drugs. Therefore, these self-administered drugs are not eligible for Part D coverage, and the Plan is not required to cover them under the Part D benefit.The Plan is not required to cover Vitamin C and Vitamin B-12 because they are also excluded from coverage. Vitamin C and Vitamin B-12 are either classified as OTC drugs or as prescription vitamin and mineral products, both of which are excluded from Medicare coverage.This decision does not address the medical necessity or appropriateness of the requested drugs. It only establishes that payment cannot be made under the Medicare Part D benefit.Regarding your request for additional reimbursement for the drugs already approved by your Plan:You asked the Plan to provide additional reimbursement for multiple self administered drugs provided. These include: Pacerone, Eliquis, Atorvastatin, Carvedilol, Losartan, or Hydroxyzine HCL. 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. The Plan submitted documentation showing that they approved coverage. They calculated reimbursement based on the total cost of the drug, less your required copayment amount, and less the difference between what the Plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital or provider's office) charged you.The case record indicates that the Plan provided coverage and reimbursement in accordance with the Part D Plan rules for out-of-network reimbursement. Therefore, our decision is the Plan is not required to provide any additional reimbursement for Pacerone, Eliquis, Atorvastatin, Carvedilol, Losartan, or Hydroxyzine HCL.Please note:Your complaint regarding Medicare's exclusion and out-of-network coverage policies is a grievance. A grievance is any complaint or dispute, other than one that involves a coverage determination or at-risk determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan. Grievance procedures are separate and distinct from appeal procedures. Medicare defines a coverage determination as (1) a decision not to provide or pay for a Part D drug, (2) failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee, (3) a decision concerning an exceptions request, or (4) a decision on the amount of cost-sharing for a drug. (42 CFR ??423.560, 423.564(b), 423.566(b)).Since your complaint involves a grievance, the Part D Plan must review this complaint under the Plan's grievance procedures. Each Part D Plan must provide meaningful procedures for timely hearing and resolving grievances between enrollees and the Part D Plan (or any other entity or individual through whom the Part D Plan provides covered benefits under any Part D Plan it offers). At this time, you should contact the Plan for information on how to proceed with having this complaint reviewed under the Plan's grievance procedures. 42 CFR Section 423.564(a).