Appeal type: Prescription Drug
Decision: Unfavorable

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 Aspirin EC, Thera M Plus, Calcium-Vitamin D3, Ferrous Sulfate, PreserVision Areds 2, Furosemide 20 mg, Hydrochlorothiazide 25 mg, Amlodipine Besylate 10 mg, Sertraline HCL 25 mg, Metoprolol Succinate ER 50 mg, Pantoprazole DR 20 mg, Potassium Chloride ER 10 meq, Quetiapine Fumarate 50 mg, Lactulose 10 gm/15 mL, Lorazepam 0.5 mg, and Losartan Potassium 50 mg and 100 mg purchased March 7, 2020 through March 27, 2020 from an in-network. The Plan did not grant this request. We received this case to conduct an independent review.Aspirin EC, Thera M Plus, Calcium-Vitamin D3, Ferrous Sulfate, PreserVision Areds 2Medicare 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, Aspirin EC, Thera M Plus, Calcium-Vitamin D3, Ferrous Sulfate, PreserVision Areds 2purchased March 10, 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.Furosemide, Hydrochlorothiazide, Amlodipine Besylate, Sertraline HCL, Metoprolol Succinate ER, Pantoprazole DR, Potassium Chloride ER, Quetiapine Fumarate, Lactulose, Lorazepam and Losartan PotassiumMedicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost. For up to a 30 day supply, the Plan required a $15 copayment for a Tier 1 drug, a $20 copayment for a Tier 2 drug and a $1 copayment for a Tier 6 drug when purchased from your pharmacy in 2020. Furosemide 20 mg, Hydrochlorothiazide 25 mg and Amlodipine Besylate 10 mg are on the Plan's 2020 Formulary and classified as Tier 1 drugs. Sertraline HCL 25 mg, Metoprolol Succinate ER 50 mg, Pantoprazole DR 20 mg, Potassium Chloride ER 10 meq, Quetiapine Fumarate 50 mg, Lactulose 10 gm/15 mL and Lorazepam 0.5 mg are on the Plan's 2020 Formulary and classified as Tier 2 drugs. Losartan Potassium 50 mg and 100 mg are on the Plan's 2020 formulary and classified as a Tier 6 drug. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that these claims were covered by the Plan at the time of purchase. The record shows that Furosemide 20 mg, Hydrochlorothiazide 25 mg, Amlodipine Besylate 10 mg, Sertraline HCL 25 mg, Metoprolol Succinate ER 50 mg, Pantoprazole DR 20 mg, Potassium Chloride ER 10 meq, Quetiapine Fumarate 50 mg, Lactulose 10 gm/15 mL, Lorazepam 0.5 mg, and Losartan Potassium 50 mg and 100 mg purchased March 7, 2020 through March 27, 2020 were purchased for an amount that is less than or equal to the required copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Furosemide 20 mg, Hydrochlorothiazide 25 mg, Amlodipine Besylate 10 mg, Sertraline HCL 25 mg, Metoprolol Succinate ER 50 mg, Pantoprazole DR 20 mg, Potassium Chloride ER 10 meq, Quetiapine Fumarate 50 mg, Lactulose 10 gm/15 mL, Lorazepam 0.5 mg, and Losartan Potassium 50 mg and 100 mg purchased March 7, 2020 through March 27, 2020.