Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to provide reimbursement for Polyethylene Glycol 3350, Docusate Sodium, Acetaminophen, Senna, Propafenone 150 mg, Metoprolol Succinate ER 25 mg, Latanoprost 0.005%, Pantoprazole DR 40 mg, Oxycodone 5 mg and Methocarbamol 500 mg and Diltiazem 30 mg and Diltiazem 5 mg/mL. The Plan did not grant this request. We received this case to conduct an independent review.  Latanoprost 0.005%, Pantoprazole DR, Oxycodone and Methocarbamol   The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received several self-administered drugs while at the hospital. You requested reimbursement from the Part D Plan. The Plan denied the request on the basis that the National Drug Code (NDC) number was not provided for the self-administered drugs. The Reconsideration appeal request includes the NDC for each drug. Latanoprost 0.005%, Pantoprazole DR, Oxycodone and Methocarbamol received while in the hospital are Part D eligible drugs. Proof of payment has been verified for the self-administered drugs. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Latanoprost 0.005%, Pantoprazole DR 40 mg, Oxycodone 5 mg and Methocarbamol 500 mg.Please note: Maximus Federal will be submitting the list of NDC numbers to the Plan with a copy of this decision letter. Polyethylene Glycol 3350, Docusate Sodium, Acetaminophen and Senna  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 a non-prescription or OTC drugs. Therefore, Polyethylene Glycol 3350, Docusate Sodium, Acetaminophen and Senna 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. Propafenone and Metoprolol Succinate ER  Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that the NDC for Propafenone and Metoprolol Succinate ER are not FDA approved for both safety and effectiveness by checking FDA sources. The NDC for Propafenone 150 mg has a market end date and the NDC for Metoprolol Succinate ER 25 mg has a market end date. Therefore, the Plan is not required to cover or provide reimbursement for Propafenone 150 mg and Metoprolol Succinate ER 25 mg.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. Diltiazem  The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received Diltiazem 30 mg and Diltiazem 5 mg/mL while at the hospital. You requested reimbursement from the Part D Plan. The Plan denied the request on the basis that the NDC for Diltiazem 30 mg and Diltiazem 5 mg/mL was not provided with your request. Although proof of payment has been verified, the NDC numbers for Diltiazem 30 mg and Diltiazem 5 mg/mL were not provided. Additionally, upon outreach to the hospital, the hospital's representative was unable to provide the NDC numbers. The Plan's out-of-network coverage rules were not followed. Therefore, our decision is the Plan is not required to provide coverage or reimbursement for Diltiazem 30 mg and Diltiazem 5 mg/mL.Please note: you may wish to reach out to the hospital and request they provide the NDCs for Diltiazem. Once received, you can submit the information to the Part D Plan.