Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Ciprofloxacin 500 mg, Hydrocodone/APAP 5/325 mg, Atorvastatin 20 mg, Tamsulosin 0.4 mg, Fenofibrate 160 mg, Aspirin EC 81 mg and Docosahexaenoic/EPA 1000 mg received while you were a patient at the hospital on May 13, 2020 through May 14, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Ciprofloxacin 500 mg, Hydrocodone/APAP 5/325 mg, Atorvastatin 20 mg, Tamsulosin 0.4 mg and Fenofibrate 160 mg:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. The Plan covers prescriptions filled at an out-of-network pharmacy when the prescriptions are for a medical emergency or urgent care. The case record shows that you received Ciprofloxacin 500 mg, Hydrocodone/APAP 5/325 mg, Atorvastatin 20 mg, Tamsulosin 0.4 mg and Fenofibrate 160 mg while you were a patient at the hospital on May 13, 2020 through May 14, 2020. This is a medical emergency or urgent care.If an enrollee uses an out-of-network pharmacy, the enrollee will generally have to pay the full cost when the prescription is filled. The enrollee can ask the Plan for reimbursement by sending the Plan a request for payment along with the receipt documenting the payment made. The case record contains proof of payment. The Plan's out-of-network coverage rules were followed.The Plan denied the request on the basis that the National Drug Code (NDC) and prescriber information (NPI) were not provided or invalid. We have confirmed that the National Provider Identification (NPI) is a valid NPI for the hospital. Medicare rules state that when a plan sponsor could acquire missing information, such as the NDC number, by contacting the enrollee's pharmacist, physician, or other prescriber, it should do so instead of relying on the enrollee to provide the information. The Plan may utilize the remainder of the 30-day payment period after approval is granted to obtain missing information in order to determine the amount of reimbursement to be provided. Thus, the Plans reimbursement rules as stated in the Evidence of Coverage have been met, and the Plan should obtain missing NDC information in order to process reimbursement. Therefore, our decision is the Plan is required to provide any applicable reimbursement for Ciprofloxacin 500 mg, Hydrocodone/APAP 5/325 mg, Atorvastatin 20 mg, Tamsulosin 0.4 mg and Fenofibrate 160 mg received while you were a patient at the hospital on May 13, 2020 and May 14, 2020.Aspirin EC 81 mg and Docosahexaeonic/EPA 10000 mg: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 drugs are non-prescription or OTC drugs. Therefore, Aspirin EC 81 mg and Docosahexaeonic/EPA 1000 mg received May 13, 2020 and May 14, 2020 while you were a patient at the hospital are 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.