Appeal type: Prescription Drug
Decision: Unfavorable

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 and Methocarbamol purchased on March 4, 2020, from your pharmacy; for HRT compound purchased on May 1, 2020, from your compounding pharmacy; and for a medical-office visit on April 27, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Regarding the request for reimbursement for Oxycodone-Acetaminophen purchased on March 4, 2020, from your pharmacy: 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 requires a $47 copayment for up to a 30-day supply of a Tier 3 drug purchased from a standard retail pharmacy in 2020. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Oxycodone-Acetaminophen 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 reimbursement for Oxycodone-Acetaminophen purchased on March 4, 2020, from your pharmacy. Regarding the request for Methocarbamol purchased on March 4, 2020, from your pharmacy: in this case, you requested coverage and reimbursement for Methocarbamol that was already covered by the Inside Rx discount coupon. According to the Inside Rx terms of use found on their website (https://insiderx.com/savings-card-terms), the discount (the Product) provided is not insurance and cannot be combined with any insurance benefit, copay assistance program, or other third-party financial benefits. When you use the Product, you are responsible for the discounted cost of your prescription(s), and you agree not to seek reimbursement for any cost incurred using this Product from any commercial or employer sponsored insurance, or any federal or state funded health care program (for instance by submitting a manual claim). When you decided to use the Inside Rx discount coupon you acknowledged and agreed that Inside Rx will be treated as the primary payor with respect to medications that you have selected to purchase through Inside Rx. Thus, Methocarbamol is not eligible for coverage or reimbursement by Part D. Therefore, it is our decision that the Plan is not required to cover or provide reimbursement for Methocarbamol purchased on March 4, 2020, from your pharmacy. Regarding the request for HRT compound (Estriol-Estradiol-Estrone-Dhea-Testosterone-Progesterone) purchased on May 1, 2020, from your compounding pharmacy: Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy stated that bulk powder was used when compounding the prescription for HRT compound. 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 HRT compound purchased on May 1, 2020, from your compounding pharmacy.This decision does not address the medical necessity or appropriateness of the requested compound drug. It only establishes if payment can be made under the Medicare Part D benefit. Regarding the request for reimbursement for a medical-office visit on April 27, 2020: Medicare Part D only covers items that meet the definition of a Part D drug. The requested item does not meet the definition of a Part D drug because it either does not require a prescription, it is not approved by the FDA for safety and effectiveness, or it is otherwise excluded. Therefore, our decision is the Plan is not required to cover or provide reimbursement for a medical-office visit on April 27, 2020. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.