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 Acetaminophen 500 mg, Belladonna Opium Suppository, Phenazopyridine 200 mg, Latanoprost 0.005%, Metoprolol ER-HCTZ 100-12.5 mg, Rosuvastatin Calcium 10 mg, Trospium Chloride 20 mg, Losartan Potassium 50 mg, Oxycodone 5 mg and Metoprolol Tartrate 25 mg received May 28, 2020 and May 29, 2020. The Plan did not grant this request. We received this case to conduct an independent review.     Acetaminophen  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, Acetaminophen received while at the hospital May 28, 2020 and May 29, 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.  Belladonna Opium Suppository and Phenazopyridine  Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Belladonna Opium Suppository and Phenazopyridine are not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the Plan is not required to cover or provide reimbursement for Belladonna Opium Suppository and Phenazopyridine received while at the hospital May 28, 2020 and May 29, 2020.  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.  Latanoprost, Metoprolol ER-HCTZ, Rosuvastatin Calcium, Trospium Chloride, Losartan Potassium, Oxycodone and Metoprolol Tartrate  The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you were at the hospital in May 2020 for an emergency medical or urgent care situation. You received several self-administered drugs during this stay. You requested reimbursement from the Part D Plan. The request includes an itemized statement for the hospital stay as well as proof of payment for the self-administered dugs. Latanoprost 0.005%, Metoprolol ER-HCTZ 100-12.5 mg, Rosuvastatin Calcium 10 mg, Trospium Chloride 20 mg, Losartan Potassium 50 mg, Oxycodone 5 mg and Metoprolol Tartrate 25 mg are Part D eligible drugs. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Latanoprost 0.005%, Metoprolol ER-HCTZ 100-12.5 mg, Rosuvastatin Calcium 10 mg, Trospium Chloride 20 mg, Losartan Potassium 50 mg, Oxycodone 5 mg and Metoprolol Tartrate 25 mg received May 28, 2020 and May 29, 2020.