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 Potassium CL ER 20 meq, Pantoprazole Sodium DR 40 mg, Nifedipine ER 30 mg, Spiriva 18 mcg handihaler, Torsemide 20 mg, Gabapentin 300 mg, Tamsulosin HCL 0.4 mg, Lisinopril 5 mg, Lidocaine 2% Viscous Solution, Eliquis 5 mg, Atorvastatin 40 mg, Ferrous Sulfate EC 325 mg and Tylenol 325 mg received August 19, 2018 through August 23, 2018 while you were a patient in the hospital. The Plan did not grant this request. We received this case to conduct an independent review.The Plan denied the request on the basis that the National Drug Code (NDC), prescriber information and an itemized statement were not provided. The Plan has made no indication in their case file that they attempted to obtain the missing information. Medicare rules state that when a plan sponsor could acquire missing information, such as the 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 Plan's 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 covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, the documents show that you were a patient August 19, 2018 through August 23, 2018 in the hospital and you submitted a request for reimbursement. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to process applicable reimbursement for Potassium CL ER 20 meq, Pantoprazole Sodium DR 40 mg, Nifedipine ER 30 mg, Spiriva 18 mcg handihaler, Torsemide 20 mg, Gabapentin 300 mg, Tamsulosin HCL 0.4 mg, Lisinopril 5 mg, Lidocaine 2% Viscous Solution, Eliquis 5 mg, Atorvastatin 40 mg received August 19, 2018 through August 23, 2018 while you were a patient in the hospital.Ferrous Sulfate EC and Tylenol: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 drug is a non-prescription or OTC drug. Therefore, Ferrous Sulfate EC and Tylenol received August 19, 2018 through August 23, 2018 while you were a patient in the hospital 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.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.