Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover and provide reimbursement for Prochlorperazine 5 mg, Acyclovir 200 mg, Famotidine 20 mg, Ondansetron ODT 4 mg, Fentanyl Transdermal Patch 12 mcg/hr, Calcium Acetate 667 mg, Hydrocodone/Acetaminophen (Norco) 7.5/325 mg, Hydrocodone/Acetaminophen 5/325 mg, Lactulose Sol 10 g/15 ml, Dapsone 100 mg, Furosemide 20 mg, Sodium Bicarbonate 650 mg, Peg 3350 Powder (Polyethylene Glyco), Dulcolax Suppository (Bisacodyl) and Vitamin D3 purchased September 14, 2019 through October 17, 2019 at the pharmacy. 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. In this case, you provided receipts for the purchase of Prochlorperazine 5 mg, Acyclovir 200 mg, Famotidine 20 mg, Ondansetron ODT 4 mg, Fentanyl Transdermal Patch 12 mcg/hr, Calcium Acetate 667 mg, Hydrocodone/Acetaminophen (Norco) 7.5/325 mg, Hydrocodone/Acetaminophen 5/325 mg, Lactulose Sol 10 g/15 ml, Dapsone 100 mg and Furosemide 20 mg. The Plan's out-of-network coverage rules were followed. The Plan denied this request stating the enrollee has another drug plan which must process the claims as the Primary Payer before Medicare will pay. Medicare records do not show that you had another prescription drug plan requiring coordination of benefits at the time the drugs were purchased. Based on the information available, the Plan has not demonstrated that they should be classified as a Secondary Payer. Therefore, our decision is the Plan is required to process applicable reimbursement for Prochlorperazine 5 mg, Acyclovir 200 mg, Famotidine 20 mg, Ondansetron ODT 4 mg, Fentanyl Transdermal Patch 12 mcg/hr, Calcium Acetate 667 mg, Hydrocodone/Acetaminophen (Norco) 7.5/325 mg, Hydrocodone/Acetaminophen 5/325 mg, Lactulose Sol 10 g/15 ml, Dapsone 100 mg and Furosemide 20 mg purchased September 14, 2019 through October 17, 2019 at the pharmacy.Sodium Bicarbonate, Peg 3350 Powder (Polyethylene Glyco) and Dulcolax Suppository (Bisacodyl):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 drugs are non-prescription or OTC drugs. Therefore, Sodium Bicarbonate, Peg 3350 Powder (Polyethylene Glyco) and Dulcolax Suppository (Bisacodyl) purchased September 14, 2019 through October 17, 2019 at the pharmacy is not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement 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.Vitamin D3:Medicare law excludes certain drugs from Part D coverage. Vitamin D3 is one of those excluded drugs because it is a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Vitamin D3. Therefore, the Plan is not required to cover or provide reimbursement for Vitamin D3. 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 that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.