Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Aspirin 81 mg, Therems-M Tab and Florastor 250 mg purchased October 25, 2019; Vitafusion Calcium with Vit D purchased October 28, 2019; and Metoprolol Succinate 50 mg, Pantoprazole DR 40 mg, Amlodipine 5 mg, Buspirone 10 mg, Donepezil 5 mg and Lisinopril 20 mg purchased October 31, 2019 from your Pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Aspirin, Therems-M Tab, Florastor and Vitafusion Calcium with Vit DMedicare 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 81 mg and Therems-M Tab and Florastor 250 mg purchased October 25, 2019 and Vitafusion Calcium with Vit D purchased October 28, 2019 from your Pharmacy 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.Metoprolol Succinate, Pantoprazole DR, Amlodipine and LisinoprilMedicare 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 $15 copayment for up to a 30 day supply of a Tier 1 drug purchased in 2019 from an in-network standard retail pharmacy. Metoprolol Succinate, Pantoprazole DR, Amlodipine and Lisinopril were on the Plan's 2019 Formulary and classified as Tier 1 drugs. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that these claims were covered by the Plan at the time of purchase. The record shows that Metoprolol Succinate, Pantoprazole DR, Amlodipine and Lisinopril were 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 Metoprolol Succinate, Pantoprazole DR, Amlodipine and Lisinopril purchased October 31, 2019 from your Pharmacy.Buspirone and DonepezilMedicare 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 $20 copayment for up to a 30 day supply of a Tier 2 drug purchased in 2019 from an in-network standard retail pharmacy. Buspirone and Donepezil were on the Plan's 2019 Formulary and classified as Tier 2 drugs. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that these claims were covered by the Plan at the time of purchase. The record shows that Buspirone and Donepezil were 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 Buspirone and Donepezil purchased October 31, 2019 from your Pharmacy.