Persius/hicric huggingface dataset:
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Oxycodone 5 milligram tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Pantoprazole Sodium delayed release 40 milligram tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Senna-lax 8.6 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Valacyclovir 500 milligram tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Verapamil 80 milligram tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone/Acetaminophen 10/325 milligram tablet prescribed for diagnosis not provided. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the Hydrocodone/Acetaminophen purchased on dates of fill February 9, 2022 and April 6, 2022. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined the purchases of the requested drug are not eligible for reimbursement without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vancomycin 125 milligram capsule prescribed to treat clostridium difficile infection. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. We reviewed the plan's 2022 Evidence of Coverage. The enrollees coinsurance for up to a 90 day supply of a tier 4 drug in the initial coverage stage is calculated at 50 percent of the approved cost of the drug. The information provided indicates the plan approved amount was $1581.60. Therefore, the enrollee's coinsurance of $790.80 was calculated correctly and no additional reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buspirone Hydrochloride 15 milligram tablet prescribed for an unspecifed diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine extended release 5 milligram capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine 25 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Trazodone 100 milligram capsules. The case was auto-forwarded by the plan.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Docycycline Hyclate 100 milligram capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Miralax 17 gram packet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sennosides-Docusate Sodium 8.6-50 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Compound Drops prescribed for cataract surgery. The case was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan provided documentation showing the enrollee requested coverage for a compounded drug. However, the Universal Claim Form for a Compounded Medication is not provided listing each ingredient, dosage, and the National Drug Codes (NDCs). Therefore, we determined the plan is not required to cover or provide reimbursement for the compounded drug. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol HFA (Proventil) 90 microgram inhaler prescribed to treat COVID-19. The case was auto-forwarded by the plan.We received a case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation includes pharmacy receipts that show the enrollee's Part D insurance was used to purchase the requested drug at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram tablet prescribed to treat COVID-19. The case was auto-forwarded by the plan.We received a case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation includes pharmacy receipts that show the enrollee's Part D insurance was used to purchase the requested drug at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Docycycline Hyclate 100 milligram capsule prescribed to treat COVID-19. The case was auto-forwarded by the plan.We received a case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation includes pharmacy receipts that show the enrollee's Part D insurance was used to purchase the requested drug at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Erythromycin 5 percent eye ointment prescribed to treat COVID-19. The case was auto-forwarded by the plan.We received a case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation includes pharmacy receipts that show the enrollee's Part D insurance was used to purchase the requested drug at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride extended release 20 milliequivalent tablet prescribed to treat COVID-19. The case was auto-forwarded by the plan.We received a case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation includes pharmacy receipts that show the enrollee's Part D insurance was used to purchase the requested drug at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydroxyzine Hydrochloride 25 milligram tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased Hydroxyzine Hydrochloride 25 milligram tablets on November 16, 2021, at the full price from a preferred retail pharmacy. 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. In this case, documentation was provided showing that this claim was covered by the plan at the time of purchase. We determined that the plan is required to reimburse the enrollee the amount of total cash price paid, minus any applicable tiered copayment/coinsurance amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 500 milligram tablet to treat chronic muscle spasms due to fibromyalgia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydroxyzine Hydrochloride 25 milligram tablet to treat pruritis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does satisfy the plans coverage criteria. The submitted prior authorization form answers all questions appropriately that are required by the plan. The enrollee is taking the drug for a diagnosis of pruritis and the prescriber has attested the benefit of therapy outweighs the potential risks.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rybelsus 7 milligram tablets to treat type 2 diabetes mellitus. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Rybelsus is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 60 milligram tablet to treat hypothyroidism. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ozempic 8 milligram per 3 milliliter solution to treat type 2 diabetes mellitus. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Ozempic 8 milligram per 3 milliliter solution is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 milligram tablets to treat type II diabetes and unspecified proteinuria. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

We have dismissed your drug benefit request for Kerendia because our records show your request does not have a coverage determination by the plan for a tiering exception request. The drug has been approved for a formulary exception request. You must first submit your drug benefit request to the plan; if they review your case and make an unfavorable or a partially favorable decision, you may then have appeal rights to file a request for a redetermination (first level of appeal). You may file a request for reconsideration after the plan issues an unfavorable or partially favorable decision to:United States Postal Service (USPS)C2C Innovative Solutions, Inc.Part D Drug ReconsiderationsP.O. Box 44166Jacksonville, FL 32231-4166UPS / FedEx OnlyC2C Innovative Solutions, Inc.Part D QIC301 W. Bay St., Suite 600Jacksonville, FL 32202
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet as anti-coagulation therapy for systemic embolism prophylaxis in a patient with history of atrial fibrillation. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Eliquis 5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viagra 100 milligram tablet to treat your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.