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 Hydrocodone-Acetaminophen 5/325 mg, DOK soft gel 100 mg and Neomy-Polymyxin B 40 mg/ml received March 4, 2019 through March 5, 2019 while a patient at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.Hydrocodone-Acetaminophen 5/325 mg - NDC 68084-895-01:In this case, the documentation shows the enrollee was in the hospital on March 4, 2019 through March 5, 2019. This was a medical emergency or urgent care. During this stay Hydrocodone-Acetaminophen 5/325 mg, a self-administered drug was administered. A request for reimbursement was submitted to the Plan. The record includes proof of payment in full for the self-administered drugs. The Plan denied Hydrocodone-Acetaminophen on the basis that it was repackaged into smaller sizes from bulk packaging. The hospital provided the National Drug Code (NDC) the enrollee received while in the hospital (NDC) 68084-0895-01. Information on the FDA National Drug Code Directory (NDC) website indicates that 68084-0895-01 is packaged in a blister package. The Plan may process the claim using this NDC. Therefore, our decision the Plan is required to process and provide any applicable reimbursement for Hydrocodone-Acetaminophen 5/325 mg received March 4, 2019 through March 5, 2019 while you were a patient in the hospital.DOK soft gel 100 mg: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, DOK soft gel 100 mg received March 4, 2019 through March 5, 2019 while you were a patient in the hospital is not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for it 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.Neomy-Polymyxin B 40 mg/ml and Hydrocodone-Acetaminophen 5/325 mg (NDC 00904-6567-61):We are dismissing Neomy-Polymyxin B 40 mg/ml and Hydrocodone-Acetaminophen 5/325 mg (NDC 00904-6567-61): The Part D Plan provided documentation that the request for coverage or payment for Neomy-Polymyxin B 40 mg/ml and Hydrocodone-Acetaminophen 5/325 mg (NDC 00904-6567-61) received March 4, 2019 through March 5, 2019 while you were a patient in the hospital was approved as requested. Since the Plan has agreed to provide coverage or payment, there is no need for a reconsideration review. Contact the Part D Plan to learn more about how and when coverage or payment will be provided for Neomy-Polymyxin B 40 mg/ml and Hydrocodone-Acetaminophen 5/325 mg (NDC 00904-6567-61) received March 4, 2019 through March 5, 2019 while you were a patient in the hospital.