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 provide reimbursement for Benzocaine-Menthol, Ipratropium-Albuterol 0.5-2.5 mg/3 mL, Memantine 10 mg, Topiramate 50 mg, Albuterol 2.5 mg/3 mL, Benazepril 5 mg, Furosemide 40 mg, Paroxetine 20 mg, Potassium Chloride 20 meq, Tamsulosin 0.4 mg, Metformin 500 mg, Metoprolol 25 mg and Prednisone 20 mg received January 21, 2020, January 22, 2020 and January 23, 2020. The Plan did not grant this request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received Ipratropium-Albuterol 0.5-2.5 mg/3 mL, Memantine 10 mg, Topiramate 50 mg, Albuterol 2.5 mg/3 mL, Benazepril 5 mg, Furosemide 40 mg, Paroxetine 20 mg, Potassium Chloride 20 meq, Tamsulosin 0.4 mg, Metformin 500 mg, Metoprolol 25 mg and Prednisone 20 mg received January 21, 2020, January 22, 2020 and January 23, 2020 (which are Part D eligible drugs) for an emergency or urgent care situation in January 2020. You requested the reimbursement from the Part D Plan. The Plan did not process the request. The Plan denied the request for Ipratropium-Albuterol, Albuterol, Memantine and Prednisone due to prior authorization criteria not being obtained prior to receiving these drugs. Because this was a hospital stay, you were not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor were they able to obtain prior authorization or off-formulary exception review. Since this was a one-time emergency stay, the Plan should provide an exception to their normal coverage rules. Additionally, the hospital is not considered a home and therefore, Ipratropium-Albuterol and Albuterol would not be eligible for coverage under Medicare Part B. There is no indication Prednisone is prescribed for transplant rejection and also not eligible for coverage under Medicare Part B. Proof of payment has been verified for the self-administered drug portion of the bill. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to cover and provide reimbursement for Ipratropium-Albuterol 0.5-2.5 mg/3 mL, Memantine 10 mg, Topiramate 50 mg, Albuterol 2.5 mg/3 mL, Benazepril 5 mg, Furosemide 40 mg, Paroxetine 20 mg, Potassium Chloride 20 meq, Tamsulosin 0.4 mg, Metformin 500 mg, Metoprolol 25 mg and Prednisone 20 mg received January 21, 2020, January 22, 2020 and January 23, 2020.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, Benzocaine-Menthol received while at the hospital January 21, 2020, January 22, 2020 and January 23, 2020 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.