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 Atorvastatin 40 mg, Isosorbide Dinitrate 5 mg, Carvedilol 3.125 mg, Tiotropium 2.5 mcg, Levothyroxine 88 mcg, Clopidogrel 75 mg, Potassium Chloride 20 MEQ, Hydroxyzine HCL 10 mg, Apixaban 5 mg, Metoprolol Succinate 50 mg, Aspirin 81 mg and Docusate Sodium 100 mg received while you were a patient at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.Atorvastatin 40 mg, Isosorbide Dinitrate 5 mg, Carvedilol 3.125 mg, Tiotropium 2.5 mcg, Levothyroxine 88 mcg, Clopidogrel 75 mg, Potassium Chloride 20 MEQ, Hydroxyzine HCL 10 mg, Apixaban 5 mg, Metoprolol Succinate 50 mg:The 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 you received Atorvastatin 40 mg, Isosorbide Dinitrate 5 mg, Carvedilol 3.125 mg, Tiotropium 2.5 mcg, Levothyroxine 88 mcg, Clopidogrel 75 mg, Potassium Chloride 20 MEQ, Hydroxyzine HCL 10 mg, Apixaban 5 mg, Metoprolol Succinate 50 mg while you were a patient at the hospital. You submitted a request for reimbursement with a copy of the hospital bill. The enrollee's reconsideration appeal request submitted in the auto forwarded case file included proof of payment in full of the self-administered drug portion of the bill. The Plan's criteria for out-of-network coverage have been met. Therefore, our decision is the Plan is required to process applicable reimbursement for Atorvastatin 40 mg, Isosorbide Dinitrate 5 mg, Carvedilol 3.125 mg, Tiotropium 2.5 mcg, Levothyroxine 88 mcg, Clopidogrel 75 mg, Potassium Chloride 20 MEQ, Hydroxyzine HCL 10 mg, Apixaban 5 mg, Metoprolol Succinate 50 mg received 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.Aspirin 81 mg and Docusate Sodium 100 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, Aspirin EC 81 mg and Docusate Sodium 100 mg, received 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.