受托人的意见
______________________________________________________________________________

在再保险

原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 11-0137 - 2017年7月26日

受托人: 迈克尔·H. 霍兰德，马蒂·D. 哈德逊和约瑟夫. Reschini

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实
The Complainant is a retiree of the Respondent and receives medical benefits coverage from the Respondent secondary to 医疗保险. The Complainant was taken by ambulance to the emergency room of his local hospital on October 5, 2015. He remained in the hospital as an observation patient until being admitted on October 8, 2015. He was discharged from the hospital on October 14, 2015. The hospital classified the Complainant as an outpatient for the period from October 5, 2015年至10月8日, 2015.

From the date the Complainant arrived at the hospital on October 5, 2015, until the date of his discharge on October 14, 2015, the hospital provided to the Complainant prescription medications that he takes on a regular, 自行管理的基础. 安泰, 被申请人的医疗索赔保险公司, denied coverage for prescription drugs administered to the Complainant during the period of October 5, 2015年至10月8日, 2015 (the period during which he received observation services at the hospital). 在上诉, 安泰 upheld the original denial and forwarded the claim for review to Maximus, the independent review organization contractor for 医疗保险. Maximus upheld 安泰’s denial decision and indicated that coverage for the drugs might be available under 医疗保险 Part D. SilverScript, the Respondent’s pharmacy benefits manager for 医疗保险-eligible beneficiaries, denied the Complainant’s claim for benefits because the National Drug Codes for the drugs the Complainant received were either incorrect or missing. Multiple telephone calls and letters to the hospital requesting the denied pharmacy charges be resubmitted with the correct codes have gone unanswered.

争端
被告是否需要支付$50.49 for medications dispensed to the Complainant from October 5, 2015年至10月8日, 2015?

双方立场
Position of the 原告: The Complainant received medications while hospitalized. 药费包括在内.

Position of the 被申请人: The Respondent did not submit a response to the complaint.

相关的规定
第三条 A(1)(a) and 第三条 A(4)(a) and (b) of the 雇主 Benefit Plan state:
第三条福利待遇
A. 健康的好处
(1)住院医疗福利
(a)半私人房间
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), 福利将提供给……

* * *

Drugs and medication (including take-home drugs which are limited to a 30-day supply)

第三条福利待遇
A. 健康的好处
(4)处方药
(a)提供的福利
Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a (i) physician for treatment or control of an illness or nonoccupational accident…

(b)排除的福利
Benefits shall not be provided under subsection (4)(a) for the following:
1. Medications dispensed in a hospital (including take-home drugs), skilled nursing facility or physician’s office. (See 第三条 A (1)(a) and (5)(a) for benefits provided for drugs and medications during inpatient confinement in a hospital skilled nursing facility.)

讨论
第三条.A(1) of the 雇主 Benefit Plan states that benefits will be provided for prescription medications dispensed by a hospital when the beneficiary has been admitted to the hospital as an inpatient. Observation services are hospital outpatient services. Based on the hospital’s designation of the Complainant as an outpatient from October 5, 2015年至10月8日, 2015, 安泰 denied the charges for the prescription medications dispensed prior to the date of the Complainant’s inpatient admission. 然而, the denial from SilverScript indicates only that the denial was due to incorrect or missing National Drug Codes. 的资金’ Senior Pharmacy Manager has reviewed the file and concluded that with the exception of the over-the-counter drugs provided, the remaining drugs administered to the Complainant as an outpatient from October 5, 2015年至10月8日, 2015, would have been covered by SilverScript with the correct coding been present at the time of billing. 因此, under the provisions of the 雇主 Benefit Plan, the Respondent is required to provide benefits for the prescription medication dispensed to the Complainant from October 5, 2015年至10月8日, 2015年的金额为41美元.79, but is not required to provide benefits for the over-the-counter medication dispensed to the Complainant in the amount of $8.70.

受托人的意见

Pursuant to the provisions of the 雇主 Benefit Plan, the Respondent is required to pay $41.79 for prescription medications dispensed to the Complainant by the hospital, 但不需要支付8美元.70 for over-the-counter medications dispensed to the Complainant by the hospital.