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.Favorable DecisionYou asked the Plan to provide reimbursement for Mucinex (Guaifenesin) 600 mg, Ferrous Sulfate 325 mg, Melatonin 3 mg, Aspirin EC 81 mg, Cetirizine 10 mg, Multivitamin. PEG (Polyethylene Glycol) 3350, Rosuvastatin 10 mg, Apixaban 5 mg, Carvedilol 12.5 mg, Pantoprazole DR 40 mg, Mometasone 220 mcg/act, Ipratropium-Albuterol 2.5 mg/3 mL, Torsemide 20 mg, Roflumilast 500 mcg, Dofetilide 250 mcg, Buspirone 5 mg, Indacaterol-Glycopyrrolate 27.5-15.6 mcg, Lorazepam 1 mg, Doxycycline Hyclate 100 mg, Ipratropium 0.2% and Prednisone 20 mg. 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 received several self-administered drugs while at the hospital for an emergency or urgent care situation. You requested reimbursement from the Part D Plan. The Plan did not process the request. Your request includes an itemized statement from the hospital and proof of payment for the self-administered drug portion of the bill. Rosuvastatin 10 mg, Apixaban 5 mg, Carvedilol 12.5 mg, Pantoprazole DR 40 mg, Mometasone 220 mcg/act, Ipratropium-Albuterol 2.5 mg/3 mL, Torsemide 20 mg, Roflumilast 500 mcg, Dofetilide 250 mcg, Buspirone 5 mg, Indacaterol-Glycopyrrolate 27.5-15.6 mcg, Lorazepam 1 mg, Doxycycline Hyclate 100 mg, Ipratropium 0.2% and Prednisone 20 mg are Part D eligible drugs. 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 they 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.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage for and reimbursement for Rosuvastatin 10 mg, Apixaban 5 mg, Carvedilol 12.5 mg, Pantoprazole DR 40 mg, Mometasone 220 mcg/act, Ipratropium-Albuterol 2.5 mg/3 mL, Torsemide 20 mg, Roflumilast 500 mcg, Dofetilide 250 mcg, Buspirone 5 mg, Indacaterol-Glycopyrrolate 27.5-15.6 mcg, Lorazepam 1 mg, Doxycycline Hyclate 100 mg, Ipratropium 0.2% and Prednisone 20 mg.Unfavorable DecisionMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Mucinex (Guaifenesin) 600 mg, Ferrous Sulfate 325 mg, Melatonin 3 mg, Aspirin EC 81 mg, Cetirizine 10 mg, Multivitamin and PEG (Polyethylene Glycol) 3350 received 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.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.