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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Proair HFA purchased January 27, 2017, February 28, 2017, January 17, 2018, January 8, 2019, and February 4, 2019. The Plan did not grant this request. We received this case to conduct an independent review.January 27, 2017 and February 28, 2017Medicare law requires that Part D Plans coordinate benefits with SPAPs, other entities providing prescription drug coverage, beneficiaries, and others paying on the beneficiaries' behalf for a period of 3years from the date on which the prescription for a covered Part D drug was filled. This means that claims for coverage and reimbursement must be submitted to the Plan within 3 years from the date of purchase. In this case, the record shows that the purchase(s) in dispute were made in January and February 2017. A request for coverage/reimbursement was not submitted to the Plan until May 2020. As a result, the claims were not submitted within the Medicare required timeframe of 3 years or less from the date the drug was filled. Therefore, our decision is that the Plan is not required to provide reimbursement for Proair HFA purchased January 27, 2017 and February 28, 2017.January 17, 2018Medicare rules state that an individual that meets requirements under Medicare's low income subsidy (LIS) rules is entitled to a reduction or elimination in the premium, a reduction or elimination in the annual deductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and a reduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extent of reduction in these benefits depends on an individual's income and resources. According to enrollment records from CMS, you were determined to be entitled to an LIS, copay level 2, effective January 1, 2018 through December 31, 2018. For copay level 2, an enrollee is required to pay a $1.25 and $3.70 copayments.In this case, the Plan provided documentation that Proair HFA was purchased on January 17, 2018 and for $3.70. The record shows that Proair HFA was purchased for an amount that is less than or equal to the required LIS copayment amount for these dates.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract and with the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required to provide reimbursement for Proair HFA purchased on January 17, 2018.January 8, 2019 and February 4, 2019Medicare rules state that an individual that meets requirements under Medicare's low income subsidy (LIS) rules is entitled to a reduction or elimination in the premium, a reduction or elimination in the annual deductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and a reduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extent of reduction in these benefits depends on an individual's income and resources. According to enrollment records from CMS, you were determined to be entitled to an LIS, copay level 2, effective January 1, 2019 through December 31, 2019. For copay level 2, an enrollee is required to pay a $1.25 and $3.80 copayments.In this case, the Plan provided documentation that Proair HFA was purchased on January 17, 2018 and for $3.80. The record shows that Proair HFA was purchased for an amount that is less than or equal to the required LIS copayment amount for these dates.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract and with the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required to provide reimbursement for Proair HFA purchased on January 8, 2019 and February 4, 2019.