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 provide reimbursement for Acetaminophen 500 mg, Multi-Vitamin, Loratadine 10 mg, Calcium Carbonate 500 mg, Metoprolol Tartrate 25 mg, Potassium Chloride ER 20 mg, Trazodone 150 mg, Buspirone 5 mg, Citalopram 20 mg, Lorazepam 1 mg and Pantoprazole DR 40 mg received June 19, 2020, June 20, 2020 and June 21, 2020 and the Shingles vaccine received July 28, 2020. The Plan did not grant this request. We received this case to conduct an independent review.   Metoprolol Tartrate, Potassium Chloride ER, Trazodone, Buspirone, Citalopram, Lorazepam and Pantoprazole DR  The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you were at the hospital for an emergency or urgent care situation in June 2020. You received several self-administered drugs during this stay.  Metoprolol Tartrate 25 mg, Potassium Chloride ER 20 mg, Trazodone 150 mg, Buspirone 5 mg, Citalopram 20 mg, Lorazepam 1 mg and Pantoprazole DR 40 mg are Part D eligible drugs. Proof of payment for these self-administered drugs has been verified. The Plan?s out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Metoprolol Tartrate 25 mg, Potassium Chloride ER 20 mg, Trazodone 150 mg, Buspirone 5 mg, Citalopram 20 mg, Lorazepam 1 mg and Pantoprazole DR 40 mg received June 19, 2020, June 20, 2020 and June 21, 2020.  Acetaminophen 500 mg, Multi-Vitamin, Loratadine 10 mg, Calcium Carbonate 500 mg,  Medicare 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, Acetaminophen 500 mg, Multi-Vitamin, Loratadine 10 mg and Calcium Carbonate 500 mg received June 19, 2020, June 20, 2020 and June 21, 2020 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.  Shingles Vaccine  The Part D Plan covers certain vaccines purchased and/or administered out-of-network. If an enrollee receives a vaccine from an out-of-network provider, the enrollee will generally have to pay the full cost for the vaccine. The enrollee may then submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost.  In this case, the record shows that you were administered the shingles vaccine on July 28, 2020. You submitted a request for reimbursement however, the record does not include proof of payment in full for the vaccine. The Plan's criteria for out-of-network coverage and reimbursement have not been met. Therefore, our decision is the Plan is not required to cover or provide reimbursement for the shingles vaccine on July 28, 2020.