Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover and provide reimbursement for Trimix compound (Alprostadil-Papaverine-Phentolamine) purchased to provide additional reimbursement for Trimix compound (Alprostadil-Papaverine-Phentolamine) purchased to cover and provide reimbursement for Sildenafil 20 mg. The Plan did not grant this request. We received this case to conduct an independent review.Regarding the request for coverage and reimbursement for Trimix compound (Aprostadil-Papaverine-Phentolamine) purchased; Medicare Part D does not cover drugs that are not FDA approved. A representative of the compounding pharmacy stated that bulk powder was used or would be used when compounding the prescription for Trimix compound (Aprostadil-Papaverine-Phentolamine). Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursement for Trimix compound (Aprostadil-Papaverine-Phentolamine). This decision does not address the medical necessity or appropriateness of Trimix compound (Aprostadil-Papaverine-Phentolamine). It only establishes if payment can be made under the Medicare Part D benefit.Regarding the request for additional reimbursement for Trimix compound (Aprostadil-Papaverine-Phentolamine) purchased; Medicare 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. The Plan required a $10 copayment amount for up to a 30-day supply of a Tier 1 drug purchased from a standard retail pharmacy. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered and reimbursed by the Plan. The record shows that Trimix compound was 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 additional reimbursement for Trimix compound (Alprostadil-Papaverine-Phentolamine). Regarding the request for coverage and reimbursement for Sildenafil 20 mg. Medicare law excludes certain drugs from Part D coverage. Sildenafil 20 mg is one of those excluded drugs because it is a drug used to treat sexual or erectile dysfunction. The record submitted by the Plan does not clearly indicate that they provide supplemental coverage for Sildenafil 20 mg. Therefore, the Plan is not required to cover or provide reimbursement for Sildenafil 20 mg.This decision does not address the medical necessity or appropriateness of Sildenafil 20 mg. It only establishes that payment cannot be made under the Medicare Part D benefit.We are dismissing the request for coverage and reimbursement for Sildenafil 20 mg. The enrollee must be a Plan member at the time the drug is requested or purchased in order for an appeal to be filed. Since you were not enrolled in the Part D Plan, when Sildenafil 20 mg was purchased, the request is dismissed.