Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to provide reimbursement for Aspirin, Cholecalciferol, Acetaminophen, Benzonatate, Guaifenesin, Albuterol-Ipratropium 3 mL, Carvedilol 25 mg, Atorvastatin 40 mg, Famotidine 20 mg, Zolpidem 5 mg, Lisinopril 20 mg, Ranolazine ER 500 mg, Levothyroxine 75 mcg and 100 mcg, Montelukast 10 mg and Dulera 200-5 mcg received December 30, 2018 through January 2, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Albuterol-Ipratropium, Carvedilol, Atorvastatin, Famotidine, Zolpidem, Lisinopril, Ranolazine ER, Levothyroxine, Montelukast and DuleraThe 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 for an emergency or urgent care situation from December 30, 2018 through January 2, 2019. You requested reimbursement from the Part D Plan. An itemized statement and proof of payment have been provided. The Plan denied the request for Albuterol-Ipratropium, Carvedilol, Atorvastatin, Famotidine, Zolpidem, Lisinopril, Ranolazine ER, Levothyroxine, Montelukast and Dulera on the basis that you did not provide the applicable National Drug Code (NDC) number for each drug. Medicare rules state that when a Plan sponsor could acquire missing information, such as the National Drug Code (NDC) number, by contacting the enrollee's pharmacist, physician, or other prescriber, it should do so instead of relying on the enrollee to provide the information. The Plan may utilize the remainder of the 30-day payment period after approval is granted to obtain missing information in order to determine the amount of reimbursement to be provided. Thus, the Plans reimbursement rules as stated in the Evidence of Coverage have been met, and the Plan should obtain missing NDC information in order to process reimbursement.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to cover and provide reimbursement for Albuterol-Ipratropium 3 mL, Carvedilol 25 mg, Atorvastatin 40 mg, Famotidine 20 mg, Zolpidem 5 mg, Lisinopril 20 mg, Ranolazine ER 500 mg, Levothyroxine 75 mcg and 100 mcg, Montelukast 10 mg and Dulera 200-5 mcg received December 30, 2018 through January 2, 2019.Aspirin, Cholecalciferol and AcetaminophenMedicare 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, Cholecalciferol and Acetaminophen received while at the hospital December 30, 2018 through January 2, 2019 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.Benzonatate and GuaifenesinMedicare law excludes certain drugs from Part D coverage. Benzonatate and Guaifenesin are excluded drugs because they are drug used for the symptomatic relief of coughs and colds. The record submitted by the Plan does not indicate that they provide supplemental coverage for Benzonatate and Guaifenesin. Therefore, the Plan is not required to cover or provide reimbursement for Benzonatate and Guaifenesin received while at the hospital December 30, 2018 through January 2, 2019.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.