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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Allopurinol, Amitriptyline, Atenolol, Diclofenac gel, Gemfibrozil, Glipizide,Levothyroxine, Losartan, Niacin, Pantoprazole, Pravastatin, ES Mapap, Omega-3 Fatty Acid, PreservisionMultivitamin, and Tylenol ES received while a patient at your local hospital. The Plan did not grant this request. We received this case to conduct an independent review.Regarding the request for Allopurinol, Amitriptyline, Atenolol, Diclofenac gel, Gemfibrozil, Glipizide, Levothyroxine, Losartan, Niacin, Pantoprazole, and Pravastatin: the Part D 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 may 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 a patient at your local hospital. You received Allopurinol, Amitriptyline, Atenolol, Diclofenac gel, Gemfibrozil, Glipizide, Levothyroxine, Losartan, Niacin, Pantoprazole, and Pravastatin for a medical emergency or urgent care. You submitted a request for reimbursement with a copy of the itemized hospital bill. The Plandenied coverage on the basis that a valid National Provider Identifier (NPI) number was not provided toidentify the prescribing physician. Medicare rules state that when a plan sponsor could acquire missinginformation, such as the NPI number, by contacting the enrollee's hospital where they received emergencyor urgent care, it should do so instead of relying on the enrollee to provide the information. The Plan mayutilize the remainder of the 30-day payment period after approval is granted to verify missing informationin order to determine the amount of reimbursement to be provided. Thus, the Plan's reimbursement rules asstated in the Evidence of Coverage have been met, and the Plan should obtain missing NPI information inorder to process reimbursement.Information in the case record indicates that you were an outpatient at your local hospital when youreceived these drugs. As such, you were not in a position to obtain the drugs that had been previously filledat 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 coveragerules.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required tocover and provide any applicable reimbursement for Allopurinol, Amitriptyline, Atenolol, Diclofenac gel,Gemfibrozil, Glipizide, Levothyroxine, Losartan, Niacin, Pantoprazole, and Pravastatin received while a patient at your local hospital.Regarding the request for ES Mapap, Omega-3 Fatty Acid, Preservision Multivitamin, and Tylenol ES: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 these drugs are non-prescription or OTCdrugs. Therefore, ES Mapap, Omega-3 Fatty Acid, Preservision Multivitamin, and Tylenol ES are noteligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for them underthe Part D benefit.This decision does not address the medical necessity or appropriateness of ES Mapap, Omega-3 Fatty Acid,Preservision Multivitamin, and Tylenol ES. It only establishes that payment cannot be made under theMedicare Part D benefit.