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 Sennosides Docusate, Tylenol, Mag-Al Plus, Metoprolol Succinate ER, Atorvastatin, Amlodipine, Gabapentin, Oxycodone, Pantoprazole DR, Tramadol, Triamterene-HCTZ, Eliquis, Celecoxib, Oxycodone ER, Furosemide and Klor-Con M ER. The Plan did not grant this request. We received this case to conduct an independent review.Metoprolol Succinate ER, Atorvastatin, Amlodipine, Gabapentin, Oxycodone, Pantoprazole DR and TramadolThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received several self-administered drugs while at the hospital. The Plan denied the request for reimbursement for Metoprolol Succinate ER 25 mg, Atorvastatin 40 mg, Amlodipine 5 mg, Gabapentin 600 mg, Oxycodone 5 mg, Pantoprazole DR 40 mg and Tramadol 50 mg due to the National Drug Code (NDC) for each of these drugs not being Part D eligible. However, we checked Medicare approved resources and verified the NDC for each of these drugs is Part D eligible:- Metoprolol Succinate ER 25 mg (NDC 60687039011)- Atorvastatin 40 mg (NDC 68084009911)- Amlodipine 5 mg (NDC 60687048811)- Gabapentin 600 mg (NDC 68084079711)- Oxycodone 5 mg (NDC 68084035411)- Pantoprazole DR 40 mg (NDC 68084081311)- Tramadol 50 mg (NDC 68084080811)The above NDCs belong to re-packaged products. Additionally, Gabapentin 600 mg has a discontinue date. It is reasonable that a hospital would provide self-administered drugs that have been discontinued and/or repackaged. The Plan's out-of-network coverage rules were followed and each of the above NDCs are for Part D eligible products. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Metoprolol Succinate ER 25 mg, Atorvastatin 40 mg, Amlodipine 5 mg, Gabapentin 600 mg, Oxycodone 5 mg, Pantoprazole DR 40 mg and Tramadol 50 mg. Sennosides Docusate, Tylenol and Mag-Al PlusMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classification or determined from other available resources that the drugs are a non-prescription or OTC drug. Therefore, Sennosides Docusate, Tylenol and Mag-Al Plus are not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for 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.Triamterene-HCTZ, Eliquis, Celecoxib, Oxycodone ER, Furosemide and Klor-Con M ERThe Part D Plan provided documentation that the request for coverage or payment for Triamterene-HCTZ, Eliquis, Celecoxib, Oxycodone ER, Furosemide and Klor-Con M ER received was approved as requested. Since the Plan has agreed to provide coverage or payment, there is no need for a reconsideration review.Contact the Part D Plan to learn more about how and when coverage or payment will be provided for Triamterene-HCTZ, Eliquis, Celecoxib, Oxycodone ER, Furosemide and Klor-Con M ER.