Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to provide reimbursement for Amlodipine Besylate 10 mg, Kombiglyze XR 2.5-1,000 mg, Letrozole 2.5 mg, Simvastatin 20 mg, Valsartan-HCTZ 320-25 mg and Warfarin Sodium 7.5 mg purchased August 8, 2020 through September 15, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Favorable Decision: Kombiglyze XR 2.5-1,000 mg purchased September 8, 2020 and September 13, 2020; Simvastatin 20 mg purchased September 13, 2020; Valsartan-HCTZ 320-25 mg purchased September 8, 2020 and September 13, 2020 and Warfarin Sodium 7.5 mg purchased September 8, 2020Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The Plan required a $0 copayment for up to a 90 day supply of a Tier 1 drug purchased in 2020 from a preferred network pharmacy. The Plan also required a $225 copayment for up to a 90 day supply of a Tier 4 drug purchased in 2020 from a preferred network pharmacy. Simvastatin 20 mg, Valsartan-HCTZ 320-25 mg and Warfarin Sodium 7.5 mg are on the Plan's 2020 formulary and classified as Tier 1 drugs. Kombiglyze XR 2.5-2,000 mg is on the Plan's 2020 formulary and classified as a Tier 4 drug.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. You purchased Simvastatin 20 mg on September 13, 2020; Valsartan-HCTZ 320-25 mg on September 8, 2020 and September 13, 2020 and Warfarin Sodium 7.5 mg on September 8, 2020 for more than the required copayment amounts. The Plan indicates that they have not yet provided coverage for these claims. The Plan has also indicated there is no reason why the claims should not be paid at this time. Kombiglyze XR 2.5-1,000 mg was purchased on September 8, 2020 and September 13, 2020 for less than the required copayment amount; however, the Plan also verified that these claims have not yet been paid nor processed by the Plan.Therefore, our decision is the Plan is required to process and provide any applicable reimbursement for Kombiglyze XR 2.5-1,000 mg purchased September 8, 2020 and September 13, 2020; Simvastatin 20 mg purchased September 13, 2020; Valsartan-HCTZ 320-25 mg purchased September 8, 2020 and September 13, 2020 and Warfarin Sodium 7.5 mg purchased September 8, 2020.Unfavorable Decision: Amlodipine Besylate 10 mg, Kombiglyze XR 2.5-1,000 mg, Letrozole 2.5 mg, Simvastatin 20 mg, Valsartan-HCTZ 320-25 mg and Warfarin Sodium 7.5 mg purchased September 15, 2020Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost. The Plan required a $0 copayment for up to a 90 day supply of a Tier 1 and Tier 2 drug purchased in 2020 from a preferred network pharmacy. The Plan also required a $225 copayment for up to a 90 day supply of a Tier 4 drug purchased in 2020 from a preferred network pharmacy. Amlodipine Besylate 10 mg, Glipizide ER 10 mg, Simvastatin 20 mg, Valsartan-HCTZ 320-25 mg and Warfarin Sodium 7.5 mg are on the Plan's 2020 formulary and classified as Tier 1 drugs. Letrozole 2.5 mg is on the Plan's 2020 formulary and classified as a Tier 2 drug. Kombiglyze XR 2.5-2,000 mg is on the Plan's 2020 formulary and classified as a Tier 4 drug. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Amlodipine Besylate 10 mg, Kombiglyze XR 2.5-1,000 mg, Letrozole 2.5 mg, Simvastatin 20 mg, Valsartan-HCTZ 320-25 mg and Warfarin Sodium 7.5 mg purchased September 15, 2020 were purchased for an amount that is less than or equal to the required copayment amounts.The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Amlodipine Besylate 10 mg, Kombiglyze XR 2.5-1,000 mg, Letrozole 2.5 mg, Simvastatin 20 mg, Valsartan-HCTZ 320-25 mg and Warfarin Sodium 7.5 mg purchased September 15, 2020.