Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover and provide reimbursement for Fluticasone (Breo Ellipta), Tiotropium (Spiriva) and Bupropion received while the enrollee was a patient at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.Fluticasone (Breo Ellipta) 100-25 mcg and Tiotropium (Spiriva) 2.5 mcg:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, the record shows the enrollee was a patient at the hospital. The enrollee received Fluticasone (Breo Ellipta) and Tiotropium (Spiriva) for a medical emergency or urgent care. You submitted a request for reimbursement with a copy of an itemized hospital bill and proof of payment in full for the self-administered drug portion of the bill.The Part D Plan denied reimbursement on the basis that the National Drug Codes (NDCs) for the requested drugs were either invalid or missing. An NDC is a required piece of information for processing claims for drugs received out-of-network. We researched the National Drug Code directory and found Fluticasone (Breo Ellipta), NDC 0173-0859-14 and Tiotropium (Spiriva) NDC 0597-0100-51 are both valid NDC numbers.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide applicable reimbursement for Fluticasone (Breo Ellipta) and Tiotropium (Spiriva) received while the enrollee was a patient at the hospital.Bupropion XL 150 mg ER:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, the record shows the enrollee was a patient at the hospital. The enrollee received Bupropion XL 150 mg ER for a medical emergency or urgent care. You submitted a request for reimbursement with a copy of an itemized hospital bill and proof of payment in full for the self-administered drug portion of the bill.In this case, the documentation shows the enrollee was a patient at the hospital for a medical emergency or urgent care. During this stay, Bupropion XL 150 mg ER, a self-administered drug was administered. A request for reimbursement was submitted to the Plan. The record includes proof of payment in full for the Bupropion XL 150 mg ER. The hospital provided the National Drug Code (NDC) the enrollee received while in the hospital, (NDC 50268-140-11). Information on the FDA National Drug Code Directory (NDC) website indicates that 50268-140-11 is a valid, Part D eligible NDC. This NDC shows Bupropion XL 150 mg ER is packaged in a blister package. The Plan may process the claim using this NDC. Therefore our decision is the Plan is required to process and provide applicable reimbursement for Bupropion XL 150 mg ER received while the enrollee was a patient in the hospital.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 notify you in writing that the case is being reviewed again and the outcome of the reopening.