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 provide reimbursement for Tramadol-Acetaminophen 37.5-325 mg, Doxycycline Hyclate 100 mg, Eliquis 5 mg, Fluticasone Propionate 50 mcg/act and Omeprazole DR 20 mg. The Plan did not grant this request. We received this case to conduct an independent review.Tramadol-AcetaminophenWe asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Tramadol-Acetaminophen 37.5-325 mg.Tramadol-Acetaminophen 37.5-325 mg is requested to treat an unknown diagnosis. The prescriber was asked to state the enrollee's diagnosis, because there was no prescriber statement of the enrollee's diagnosis in the case file. The prescriber was also asked to address medical necessity for the requested drug. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication asdefined by Medicare law. In addition, an exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer needed additional information from the prescriber to determine whether the enrollee is using Tramadol-Acetaminophen 37.5-325 mg for an FDA-approved use, or a use listed in the Medicare-approved compendia. The requested information was not received. As a result, we could not confirm that the drug is being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit. An exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage or reimbursement for Tramadol-Acetaminophen 37.5-325 mg.This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.Fluticasone Propionate and Omeprazole DRMedicare 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 an $18 copayment for up to a 90 day supply of a Tier 2 drug purchased from a preferred retail pharmacy. Fluticasone Propionate 50 mcg/act and Omeprazole DR 20 mg are on the Plan's 2020 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 Fluticasone Propionate 50 mcg and Omeprazole DR 20 mg 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 Fluticasone Propionate 50 mcg and Omeprazole DR 20 mg.Doxycycline Hyclate and Eliquis,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 required an $37 copayment for up to a 30 day supply of a Tier 3 drug purchased from a preferred retail pharmacy. Doxycycline Hyclate 100 mg and Eliquis 5 mg are on the Plan's 2020 formulary and classified as Tier 3 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 Doxycycline Hyclate 100 mg and Eliquis 5 mg 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 Doxycycline Hyclate 100 mg and Eliquis 5 mg.