Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover and provide reimbursement for Requip XL 2 mg received while you were apatient at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.The Plan was asked to provide coverage and reimbursement for Requip XL 2 mg while you were a patientat the hospital; purchased while a patient at hospital. The Plan did not grant this request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. ThePlan covers prescriptions filled at an out-of-network pharmacy when the prescription is for a medical emergencyor urgent care. The case record shows that you received Requip XL 2 mg while you were a patient at thehospital. 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 theprescription is filled. The enrollee can ask the Plan for reimbursement by sending the Plan a request for paymentalong with the receipt documenting the payment made. The case record contains proof of payment. The Plan'sout-of-network coverage rules were followed.The Plan denied the request on the basis that a valid National Drug Code (NDC) was not provided. Medicarerules state that when a plan sponsor could acquire missing information, such as the NDC number, by contactingthe enrollee's pharmacist, physician, or other prescriber, it should do so instead of relying on the enrollee toprovide the information. The Plan may utilize the remainder of the 30-day payment period after approval isgranted to obtain missing information in order to determine the amount of reimbursement to be provided.Upon request to MAXIMUS, you provided an NDC of 00007-4885-13 for Requip XL 2 mg while you were apatient at the hospital. You also provided an itemizedstatement showing the NDC of 00007-4885-13 from the hospital. We verified that Requip XL 2 mg NDC00007-4885-13, was at one time an active FDA approved prescription drug product eligible for Part D coverage.The NDC was active until discontinued. Your hospital stay however, it is reasonable that this medication was provided with the discontinued NDC during this time period. Therefore, our decision is the Plan is required to process the claim for Requip XL 2 mg while you were a patient at the hospital. (NDC 00007-4885-13).Please note, the Plan may have had other coverage rules for this drug, such as ensuring the drug was prescribedfor a medically-accepted indication, which have not been reviewed as part of this appeal. MAXIMUS isdirecting the Plan to process this claim as rules for obtaining out-of-network review have now been met. ThePlan may notify you if there are any other coverage issues that need to be addressed when they process thisclaim.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notifyyou in writing that the case is being reviewed again and the outcome of the reopening.