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 and provide reimbursement for Tramadol 50 mg, Humulin R, Gabapentin 300 mg, Hydrocodone/Acetaminophen 5/325 mg, Atorvastatin 20 mg, Lisinopril 20 mg and Cimetidine 400 mg, Cyanocobalamin, Cholecalciferol (Vitamin D3), Sennosides-Docusate, Acetaminophen 325 mg and Aspirin 81 mg you received May 30, 2020 through May 31, 2020 while you were a patient at the hospital.Tramadol 50 mg, Humulin R, Gabapentin 300 mg, Hydrocodone/Acetaminophen 5/325 mg, Atorvastatin 20 mg, Lisinopril 20 mg and Cimetidine 400 mg: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 May 30, 2020 through May 31, 2020. You received Tramadol 50 mg, Humulin R, Gabapentin 300 mg, Hydrocodone/Acetaminophen 5/325 mg, Atorvastatin 20 mg, Lisinopril 20 mg and Cimetidine 400 mg, for a medical emergency or urgent care. You submitted a request for reimbursement with a copy of the hospital bill along with proof of payment for the self-administered drugs. The Plan's criteria for out-of-network coverage have been met. Therefore, our decision is the Plan is required to process and provide applicable reimbursement for Tramadol 50 mg, Humulin R, Gabapentin 300 mg, Hydrocodone/Acetaminophen 5/325 mg, Atorvastatin 20 mg, Lisinopril 20 mg and Cimetidine 400 mg you received May 30, 2020 through May 31, 2020 while you were a patient at the hospital.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.Cyanocobalamin and Cholecalciferol (Vitamin D3):Medicare law excludes certain drugs from Part D coverage. Cyanocobalamin and Cholecalciferol (Vitamin D3) are two of those excluded drugs because they are a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Cyanocobalamin and Cholecalciferol (Vitamin D3). Therefore, the Plan is not required to cover Cyanocobalamin and Cholecalciferol (Vitamin D3) received May 30, 2020 through May 31, 2020 while you were a patient at the hospital.Sennosides-Docusate, Acetaminophen 325 mg and Aspirin 81 mg:Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs classifications or determined from other available resources that the drugs are a non-prescription or OTC drugs. Therefore, Sennosides-Docusate, Acetaminophen 325 mg and Aspirin 81 mg received May 30, 2020 through May 31, 2020 while you were a patient at the hospital, 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.