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 Oxycodone/Acetaminophen (Percocet) 5 mg/325 mg, Tamsulosin Hydrochloride (Flomax) 0.4 mg, Allopurinol (Zyloprim) 100 mg, Gabapentin (Neurontin) 300 mg, Losartan Potassium 50 mg, Sertraline Hydrochloride (Zoloft) 100 mg, Hydrochloride/Acetaminophen 5 mg/325 mg, Carvedilol 12.5 mg, Amiodarone HCL 200 mg, Furosemide 20 mg, Synthroid (Levothyroxine) 150 mcg, Flecainide Acetate (Tambocor) 100 mg, Aspirin EC 81 mg and Therems (Theragran) received while you were a patient at the hospital on March 11, 2020 through March 12, 2020.The Plan did not grant this request. We received this case to conduct an independent review.Oxycodone/Acetaminophen (Percocet) 5 mg/325 mg, Tamsulosin Hydrochloride (Flomax) 0.4 mg, Allopurinol (Zyloprim) 100 mg, Gabapentin (Neurontin) 300 mg, Losartan Potassium 50 mg, Sertraline Hydrochloride (Zoloft) 100 mg:In this case, the documentation shows the enrollee was a patient at the hospital on March 11, 2020 through March 12, 2020. This was a medical emergency or urgent care. During this stay Oxycodone/Acetaminophen (Percocet) 5 mg/325 mg, Tamsulosin Hydrochloride (Flomax) 0.4 mg, Allopurinol (Zyloprim) 100 mg, Gabapentin (Neurontin) 300 mg, Losartan Potassium 50 mg, Sertraline Hydrochloride (Zoloft) 100 mg, self-administered drugs were administered. A request for reimbursement was submitted to the Plan. The record includes proof of payment in full for the self-administered drugs received while you were a patient in the hospital on March 11, 2020 through March 12, 2020. The Plan denied for Oxycodone/Acetaminophen (Percocet) 5 mg/325 mg, Tamsulosin Hydrochloride (Flomax) 0.4 mg, Allopurinol (Zyloprim) 100 mg, Gabapentin (Neurontin) 300 mg, Losartan Potassium 50 mg, Sertraline Hydrochloride (Zoloft) 100 mg on the basis that they were repackaged into smaller sizes from bulk packaging. The hospital provided the National Drug Codes (NDC) you received while in the hospital for Oxycodone/Acetaminophen (Percocet) 5 mg/325 mg (NDC 68084-0355-01) Tamsulosin Hydrochloride (Flomax) 0.4 mg (NDC 68084-299-01), Allopurinol (Zyloprim) 100 mg (NDC 62584-988-01), Gabapentin (Neurontin) 300 mg (NDC 68084-0762-01), Losartan Potassium 50 mg (NDC 68084-347-01), Sertraline Hydrochloride (Zoloft) 100 mg (NDC 60687-253-01) Information on the FDA National Drug Code Directory (NDC) website indicates that these NDC numbers are valid, Part D eligible NDC. This NDC shows these drugs are packaged in a blister package. The Plan may process the claim using these NDC numbers. Therefore, our decision is the Plan is required to process and provide any applicable reimbursement for Oxycodone/Acetaminophen (Percocet) 5 mg/325 mg, Tamsulosin Hydrochloride (Flomax) 0.4 mg, Allopurinol (Zyloprim) 100 mg, Gabapentin (Neurontin) 300 mg, Losartan Potassium 50 mg, Sertraline Hydrochloride (Zoloft) 100 mg.Please note, the Plan may have had other coverage rules for these drugs, such as prior authorization, which have not been reviewed as part of this appeal. MAXIMUS is directing the Plan to process this claim as rules for obtaining out-of-network review have now been met. The Plan may notify you if there are any other coverage issues that need to be addressed when they process this claim.Hydrochloride/Acetaminophen 5 mg/325 mg:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, the Plan denied reimbursement for Hydrochloride/Acetaminophen on the basis that anInvalid and or discontinued National Drug Codes (NDCs) was given by the provider. We verified Hydrochloride/Acetaminophen NDC 51079-0777-20 was at one time an active FDA approved prescription drug product eligible for Part D coverage. The NDC was active until discontinued December 31, 2019. The enrollee's hospital stay was in 2020; however, it's reasonable that this medication was provided with the expired NDC during the 2020 time period. Therefore, our decision is the Plan is required to process the claim for Hydrochloride/Acetaminophen (NDC 51079-0777-20) received March 11, 2020 through March 12, 2020 while a patient at the hospital.Please note, the Plan may have had other coverage rules for this drug, such as prior authorization, which have not been reviewed as part of this appeal. MAXIMUS is directing the Plan to process this claim as rules for obtaining out-of-network review have now been met. The Plan may notify you if there are any other coverage issues that need to be addressed when they process this claim.Aspirin EC 81 mg and Therems (Theragran):Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Aspirin EC 81 mg and Therems (Theragran) received while you were a patient at the hospital on March 11, 2020 through March 12, 2020 are not eligible for Part D coverage, and the Plan is not required to cover them under the Part D benefit.