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 and provide reimbursement for Gabapentin 300 mg, Hydrochlorothiazide 50 mg, Misoprostol 100 mcg, Naproxen 500 mg, Omeprazole DR 40 mg, Pyridostigmine Bromide, Spironolactone 50 mg, Sulfasalazine 500 mg and Naproxen Sodium 550 mg purchased from two pharmacies. The Plan did not grant this request. We received this case to conduct an independent review.Gabapentin 300 mg, Hydrochlorothiazide 50 mg, Misoprostol 100 mcg, Naproxen 500 mg, Omeprazole DR 40 mg, Pyridostigmine Bromide, Spironolactone 50 mg, Sulfasalazine 500 mg:Medicare 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 Gabapentin 300 mg, Hydrochlorothiazide 50 mg, Misoprostol 100 mcg, Naproxen 500 mg,Omeprazole DR 40 mg, Pyridostigmine Bromide, Spironolactone 50 mg and Sulfasalazine 500 mg purchased from two pharmacies. The case record includes proof of payment. Medicare rules allow a Part D Plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Gabapentin 300 mg, Hydrochlorothiazide 50 mg, Misoprostol 100 mcg, Naproxen 500 mg, Omeprazole DR 40 mg, Pyridostigmine Bromide, Spironolactone 50 mg and Sulfasalazine 500 mg 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 Gabapentin 300 mg, Hydrochlorothiazide 50 mg, Misoprostol 100 mcg, Naproxen 500 mg, Omeprazole DR 40 mg, Pyridostigmine Bromide, Spironolactone 50 mg and Sulfasalazine 500 mg purchased from two pharmacies.Naproxen Sodium 550 mg:We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Naproxen Sodium 550 mg tablet. The drug is requested to treat chronic pain syndrome. Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the formulary alternatives tried and failed. The prescriber statement was returned. The prescriber has not indicated why all NSAID alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. 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 or provide reimbursement for Naproxen Sodium 550 mg, purchased at the pharmacy.