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 applicable reimbursement for several self-administered drugs provided while at the hospital. These drugs include: Levothyroxine Sodium 75 mcg, Lorazepam 0.5 mg, Ibuprofen 400 mg, Montelukast Sodium 10 mg, Mirtazapine 15 mg, Baclofen 10 mg, Lidocaine 5% patch, Celecoxib, Naproxen 250 mg, Quetiapine Fumarate 25 mg, Sucralfate 1 g, Methocarbamol 500 mg, Pantoprazole 40 mg, Zolpidem 5 mg, Potassium Chloride 10 MEQ, Senna, APAP, Docusate Sodium and Magnesium Hydroxide. The Plan did not grant this request. We received this case to conduct an independent review.Regarding the drugs the Plan is required to cover:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received self-administered drugs while you were in the hospital. Proof of payment and an itemized list was included with this request.Some of these drugs may have had criteria that needed to be met in order for the Plan to cover them. Because this was a hospital stay, 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 any other exception review. Since this was an emergency stay, the Plan should provide a one-time exception to their normal coverage rules for this case.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and applicable reimbursement for Levothyroxine Sodium 75 mcg, Lorazepam 0.5 mg, Ibuprofen 400 mg, Montelukast Sodium 10 mg, Mirtazapine 15 mg, Baclofen 10 mg, Lidocaine 5% patch, Celecoxib, Naproxen 250 mg, Quetiapine Fumarate 25 mg, Sucralfate 1 g, Methocarbamol 500 mg, Pantoprazole 40 mg, Zolpidem 5 mg, and Potassium Chloride 10 MEQ provided to you while at the hospital. Regarding the drugs the Plan is not required to cover: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 these drugs are non-prescription or OTC drugs. Therefore, Senna, APAP, Docusate Sodium and Magnesium Hydroxide are not eligible for Part D coverage, and the Plan is not required to cover them under the Part D benefit.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.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.