Appeal type: Prescription Drug
Decision: Partially Favorable

Our decision is that the Plan is required to recalculate coverage as secondary payer and provide any applicable reimbursement for Sertraline HCL 100mg Tab, Doxepin HCL 25mg Cap, Estradiol 1mg Tab, Topiramate 100mg Tab, Cefdinir 300mg Tab, Prednisone 10mg Tab, Hydrocodone-Acetaminophen 10/325 Tab, and Hydrocodone-Acetaminophen 5/325 Tab.Medicare law states that Part D sponsors are required to coordinate with other providers of prescription drug coverage with respect to the payment of premiums and coverage, as well as coverage supplementing the benefits available under Part D. Which insurance company provides benefits first will depend on the situation.You submitted documentation showing that you paid for prescription drugs purchased from the Pharmacy filled between February 6, 2020 and March 19, 2020. The documentation also shows that you have a primary insurance company and a secondary insurance company.Sertraline HCL 100mg Tab is part D eligible on Tier 1 of the Plan's 2020 Formulary, Doxepin HCL 25mg Cap is part D eligible on Tier 4 of the Plan's 2020 Formulary, Estradiol 1mg Tab is part D eligible on Tier 1 of the Plan's 2020 Formulary, Topiramate 100mg Tab is part D eligible on Tier 2 of the Plan's 2020 Formulary, Cefdinir 300mg Tab is part D eligible on Tier 2 of the Plan's 2020 Formulary, Prednisone 10mg Tab is part D eligible on Tier 2 of the Plan's 2020 Formulary, Hydrocodone-Acetaminophen 10/325 Tab is part D eligible on Tier 3 of the Plan's 2020 Formulary, and Hydrocodone-Acetaminophen 5/325 Tab are Part D eligible on Tier 3 of the Plan's 2020 Formulary. The Plan did not provide any documentation that the claims have been processed at this time and the Plan has not provided any reason why they should not be processed or any applicable reimbursement to be provided at this time.Medicare law excludes certain drugs from Part D coverage. Promethazine with codeine solution is one of those excluded drugs because it is a 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 Promethazine with codeine solution. Therefore, the Plan is not required to cover Promethazine with codeine solution.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, Guaifen & Codeine Solution is not eligible for Part D coverage, and the Plan is not required to cover 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.Therefore, it is our decision that the Plan is required to recalculate coverage as secondary payer and provide any applicable reimbursement for Sertraline HCL 100mg Tab, Doxepin HCL 25mg Cap, Estradiol 1mg Tab, Topiramate 100mg Tab, Cefdinir 300mg Tab, Prednisone 10mg Tab, Hydrocodone-Acetaminophen 10/325 Tab, and Hydrocodone-Acetaminophen 5/325 Tab purchased from February 6, 2020 through March 19, 2020, less any applicable copayment amount.Your Part D Plan must cover Sertraline HCL 100mg Tab, Doxepin HCL 25mg Cap, Estradiol 1mg Tab, Topiramate 100mg Tab, Cefdinir 300mg Tab, Prednisone 10mg Tab, Hydrocodone-Acetaminophen 10/325 Tab, and Hydrocodone-Acetaminophen 5/325 Tab according to Medicare rules. This also means that ARCADIAN HEALTH PLAN, INC is not required to cover Promethazine with codine solution and Guaifen & Codeine Solution according to Medicare rules.