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 Clonazepam .5 mg, Donepezil HCL 10 mg, Fish Oil, Lactobacillus (Floranex), Aspirin, Acetaminophen 325 mg, Multi Minerals, Calcium Plus Vitamin D3, Lamictal (Lamotrigine) 20 mg, Pantoprazole 40 mg, Ropinirole .25 mg, Crestor (Rosuvastatin) 20 mg, Effexor XR 150 mg and Xarelto (Rivaroxaban) 15 mg received January 16, 2020 while you were a patient at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.Clonazepam .5 mg:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. The record shows you received Clonazepam .5 mg January 16, 2020 while you were a patient at the hospital. The Plan denied coverage stating that the National Drug Code (51079-0881-20) was a non-participating manufacturer. We checked Medicare approved resources and found that this was repackaged into smaller sizes from bulk packaging and NDC 51079-0881-20 is a valid, Part D eligible NDC. This NDC shows Clonazepam .5 mg is packaged in a blister package. The Plan may process the claim using this NDC. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to process applicable reimbursement for Clonazepam .5 mg received January 16, 2020 while you were a patient at the hospital.Please note, the Plan may have had other coverage rules for these drugs, such as prior authorization, which have not been reviewed as part of this appeal. MAXIMUS is directing the Plan to process these claims as rules for obtaining out-of-network review have now been met. The Plan may notify you if there are any other coverage issues that need to be addressed when they process this claim.Donepezil HCL 10 mg:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, the Plan denied reimbursement for Donepezil HCL 10 mg on the basis that invalid National Drug Codes (NDCs) were given by the provider. We verified with Medicare approved resources and found that NDC 0090-46409-61 had been discontinued in 2019. We verified Donepezil HCL 0090-46409-61 is an FDA approved prescription drug product that is eligible for Part D coverage. The enrollee's hospital stay was in 2020; however, it's reasonable that this medication was provided with the expired NDC during the 2020 time period. Therefore, our decision is the Plan is required to process the claim for Donepezil HCL 10 mg received January 16, 2020 while you were a patient at the hospital.Please note, the Plan may have had other coverage rules for these drugs, such as prior authorization, which have not been reviewed as part of this appeal. MAXIMUS is directing the Plan to process these claims as rules for obtaining out-of-network review have now been met. The Plan may notify you if there are any other coverage issues that need to be addressed when they process this claim.Fish Oil, Lactobacillus (Floranex), Aspirin and Acetaminophen 325 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 drug is a non-prescription or OTC drug. Therefore, Fish Oil, Lactobacillus (Florauex), Aspirin and Acetaminophen 325 mg received January 16, 2020 while you were a patient at the hospital are not eligible for Part D coverage, and the Plan is not required to cover them 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.Multi Minerals and Calcium Plus Vitamin D3:Medicare law excludes certain drugs from Part D coverage. Multi Minerals and Calcium Plus Vitamin D3 are those excluded drugs because they are a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Multi Minerals and Calcium Plus Vitamin D3. Therefore, the Plan is not required to cover Multi Minerals and Calcium Plus Vitamin D3 received January 16, 2020 while you were a patient at the hospital. 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.