Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to provide reimbursement for Vitamin D3, Tylenol (Acetaminophen), Alprazolam 0.25 mg, Doxazosin 1 mg, Metoprolol Succinate SR 100 mg, Spironolactone 25 mg, Pantoprazole DR 40 mg, Clonidine 0.1 mg, Clopidogrel 75 mg and additional reimbursement for Clopidogrel 300 mg received November 13, 2019 and November 14, 2019 while at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.   Alprazolam, Doxazosin, Metoprolol Succinate SR, Spironolactone, Pantoprazole DR, Clonidine and Clopidogrel  Medicare rules require a Part D Plan to issue a coverage decision or a redetermination decision within the specified timeframes. If the Plan does not make a timely decision, this is considered a denial. In these circumstances, the Plan is required to forward the coverage request or the redetermination request to the Part D QIC. The case record indicates multiple requests were submitted to the Plan for all self-administered drugs listed in the itemized statement from the hospital. The Plan did not properly process these requests to move the case forward to the next appeal level. Therefore, the applicable time frames have been exceeded, and the Part D QIC has jurisdiction to process this case for all self-administered drugs listed in the itemized statement from the hospital.   The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you were in the hospital in November 2019. During this stay you received several self-administered drugs for an emergency or urgent care situation. You requested reimbursement from the Part D Plan. The Plan did not process the request. The file submitted by the Plan includes an itemized statement from the hospital and proof of payment in full for the self-administered drug portion of the bill. The Plan's file does not verify that coverage or reimbursement has been provided for Alprazolam 0.25 mg, Doxazosin 1 mg, Metoprolol Succinate SR 100 mg, Spironolactone 25 mg, Pantoprazole DR 40 mg, Clonidine 0.1 mg and Clopidogrel 75 mg. The Plan denies reimbursement for Clonidine on the basis that a re-packaged product was provided. The Plan failed to provide the National Drug Code (NDC) for the Clonidine product administered. 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. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Alprazolam 0.25 mg, Doxazosin 1 mg, Metoprolol Succinate SR 100 mg, Spironolactone 25 mg, Pantoprazole DR 40 mg, Clonidine 0.1 mg and Clopidogrel 75 mg received November 13, 2019 and November 14, 2019.  Vitamin D3 and Tylenol (Acetaminophen)  Medicare 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 non-prescription or OTC drugs. Therefore, Vitamin D3 and Tylenol (Acetaminophen) received while at the hospital on November 13, 2019 and November 14, 2019 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.  Clopidogrel 300 mg  The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. The Plan submitted documentation showing that they approved coverage of Clopidogrel 300 mg. They calculated reimbursement based on the total cost of the drug, less your required copayment amount, and less the difference between what the Plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital or provider's office) charged you.    The case record indicates that the Plan provided coverage and reimbursement in accordance with the Part D Plan rules for out-of-network reimbursement. Therefore, our decision is the Plan is not required to provide any additional reimbursement for Clopidogrel 300 mg received November 13, 2019.