Appeal type: Prescription Drug
Decision: Unfavorable

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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover or provide reimbursement for Apixaban 5 mg, Celecoxib 200 mg, Clonidine .1mg, Estradiol 1 mg, Furosemide 40 mg, Guainfacine 600 mg, Levothyroxine .075 mcg, Magnesium Oxide400 mg, Montelukast 10 mg, Pregabalin 100 mg, Spironolactone 25 mg, Tramadol 50 mg, Verapamil XR180 mg, Acetaminophen (APAP) 325 mg, Aspirin EC (ASA) 325 mg and MVI Therapeutic tab receivedJanuary 10, 2020 through January 15, 2020 while you were a patient at the hospital. The Plan did not grantthis request. We received this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limitedcircumstances. If an enrollee must use an out-of-network pharmacy, the enrollee will generally have to paythe full cost when the prescription is filled. The enrollee may submit a request for reimbursement withproof of payment to ask the Plan to pay its share of the cost.In this case, the record shows that you were a patient at the hospital from January 10, 2020 through January15, 2020. You received Apixaban 5 mg, Celecoxib 200 mg, Clonidine .1 mg, Estradiol 1 mg, Furosemide40 mg, Guainfacine 600 mg, Levothyroxine .075 mcg, Magnesium Oxide 400 mg, Montelukast 10 mg,Pregabalin 100 mg, Spironolactone 25 mg, Tramadol 50 mg, Verapamil XR 180 mg, Acetaminophen(APAP) 325 mg, Aspirin EC (ASA) 325 mg and MVI Therapeutic tab received January 10, 2020 throughJanuary 15, 2020 while you were a patient at the hospital for a medical emergency or urgent care. Yousubmitted a request for reimbursement with a copy of an itemized hospital bill. However, the record doesnot include proof of payment in full of the self-administered drug portion of the bill. The Plan's criteria forout-of-network coverage and reimbursement have not been met. Therefore, our decision is the Plan is notrequired to cover or provide reimbursement for Apixaban 5 mg, Celecoxib 200 mg, Clonidine .1 mg,Estradiol 1 mg, Furosemide 40 mg, Guainfacine 600 mg, Levothyroxine .075 mcg, Magnesium Oxide 400mg, Montelukast 10 mg, Pregabalin 100 mg, Spironolactone 25 mg, Tramadol 50 mg, Verapamil XR 180mg, received January 10, 2020 through January 15, 2020 while you were a patient at the hospital.Acetaminophen (APAP) 325 mg, Aspirin EC (ASA) 325 mg and MVI Therapeutic tab:Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug'sclassification or determined from other available resources that the drug is a non-prescription or OTC drug.Therefore, Acetaminophen (APAP) 325 mg, Aspirin EC (ASA) 325 mg and MVI Therapuetic tab are noteligible 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 onlyestablishes that payment cannot be made under the Medicare Part D benefit.