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 Alendronate Sodium 70 mg tablet, Amoxicillin-Clavulanic, Colchicine 0.6 mg, Diclofenac Sodium 100 mg, Donepezil HCL 5 mg, Hydroxychloroquine, Methylprednisolone, Mirtazapine, Prednisone, Tramadol HCL, Ibuprofen 400 mg, Vitamin D3, Aspirin EC, Polyethylene Glycol, Citracal, and Ocuvite. The Plan did not grant this request. We received this case to conduct an independent review.Ibuprofen 400 mg; Methylprednisolone; Prednisone; Tramadol; Mirtazapine; Hydroxychloroquine; Donepezil; Amoxicillin-Clavulanic; Alendronate SodiumMedicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription drug out-of-pocket you can ask the Plan to pay you back. When submitting a request for reimbursement, the Plan requires that you submit your receipt documenting the payment you have made along with your reimbursement request. In this case, you submitted a request for reimbursement to the Plan for Ibuprofen 400 mg purchased; Methylprednisolone; Prednisone; Tramadol; Mirtazapine; Hydroxychloroquine; Donepezil; Amoxicillin-Clavulanic; Alendronate Sodium. The case record includes include proof of payment. Medicare rules allow a Part D Plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Ibuprofen 400 mg, Methylprednisolone, Prednisone, Tramadol, Mirtazapine, Hydroxychloroquine, Donepezil, Amoxicillin-Clavulanic, and Alendronate Sodium are on the Plan's formulary and are not subject to any of these restrictions. Therefore, our decision is the Plan is required to cover and provide any applicable reimbursement for Ibuprofen 400 mg; Methylprednisolone; Prednisone; Tramadol; Mirtazapine; Hydroxychloroquine; Donepezil; Amoxicillin-Clavulanic; Alendronate Sodium.Mirtazapine; Donepezil; Alendronate SodiumMedicare 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 $10 copayment for up to a 31 day supply of a Tier 1 drug purchased from a Care Facility and the Plan required a $20 copayment for up to a 31 day supply of a Tier 2 drug purchased from a Care Facility. 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 for greater than the required $10 and $20 copayment. Therefore, Mirtazapine; Donepezil; Alendronate Sodium need to be processed for applicable reimbursement.The case record indicates that the Plan did not provide coverage in accordance with the Part D contract. Therefore, our decision is the Plan is required to provide reimbursement for Mirtazapine; Donepezil; Alendronate Sodium.Ibuprofen 400 mg; TramadolMedicare 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 $10 copayment for up to a 31 day supply of a Tier 1 drug purchased from a Care Facility and a $20 copayment for up to a 31 day supply of a Tier 2 drug purchased from a Care Facility. 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 Ibuprofen 400 mg and Tramadolwere 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 Ibuprofen 400 mg; Tramadol.HydroxychloroquineIn this case, the records show that when Hydroxychloroquine was purchased, the claim straddled both the deductible stage and the initial coverage stage of the Part D benefit. An enrollee is responsible for the full cost of covered drugs until the deductible amount $435 is satisfied. The initial coverage phase requires a $47 copayment amount for this drug and day supply purchased. The Plan documentation also shows that there was $129.45 remaining in the deductible phase of coverage. This amount is subtracted from the total cost of the drug. This left a remaining total drug cost owed of $124.8 This remaining balance was subject to the initial coverage stage $47 copayment amount. $47 of the remaining balance is $77.8. The total of the two figures owed during each benefit phase (deductible and initial coverage) is $202.6. The record shows that the enrollee was charged an amount that is less than or equal to the required copayment for each phase the claim was processed in. The cost was applied to your yearly true out-of-pocket (TrOOP) costs.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, the Plan is not required to provide additional payment and/or reimbursement for Hydroxychloroquine.ColchicineWe asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Colchicine, which is not on the Plan's formulary. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the drugs offered by the Plan would: (1) not be as effective as the requested non-formulary drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Colchicine.Vitamin D3, Polyethylene Glycol, Ocuvite, Citracal, Aspirin ECMedicare 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, Vitamin D3, Polyethylene Glycol, Ocuvite, Citracal, and Aspirin ED are not eligible for Part D coverage, and the Plan is not required to cover 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.