Appeal type: Prescription Drug
Decision: Partially Favorable

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 Chlorthalidone 25 mg purchased March 10, 2020, March 25, 2020, May 7, 2020, June 18, 2020 and July 17, 2020; Clonazepam 1 mg purchased April 29, 2020, June 9, 2020 and July 6, 2020;  Hydroxyzine HCL 25 mg purchased March 10, 2020 and March 24, 2020; Losartan 25 mg purchased April 29, 2020; Potassium Chloride ER 10 meq purchased March 10, 2020; Telmisartan 40 mg purchased March 10, 2020; Telmisartan 80 mg purchased March 17, 2020; Clonidine 0.2 mg purchased June 9, 2020; Losartan 100 mg purchased July 16, 2020; and Losartan 50 mg purchased June 18, 2020. The Plan did not grant this request. We received this case to conduct an independent review.   Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. You purchased a 30 day supply of Chlorthalidone 25 mg on June 18, 2020 and July 17, 2020; Clonazepam 1 mg on June 9, 2020 and July 6, 2020; Clonidine 0.2 mg on June 9, 2020; Losartan 100 mg on July 16, 2020; and Losartan 50 mg on June 18, 2020. Clonidine 0.2 mg is on Tier 1 of the Plan?s 2020 Formulary. Chlorthalidone 25 mg and Losartan 50 mg and 100 mg are on Tier 2 of the Plan?s 2020 Formulary. Clonazepam 1 mg is on Tier 3 of the Plan?s 2020 Formulary.  The Part D Plan did not provide any evidence that these claims paid at the time of purchase, nor have they paid since they were purchased. The Plan did not provide any reason why these claims should not pay at this time. The Plan verified the pharmacy used is a preferred in-network pharmacy. Receipts were provided for each purchase.  The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is required to cover and provide reimbursement for Chlorthalidone 25 mg purchased June 18, 2020 and July 17, 2020; Clonazepam 1 mg purchased June 9, 2020 and July 6, 2020; Clonidine 0.2 mg purchased June 9, 2020; Losartan 100 mg purchased July 16, 2020; and Losartan 50 mg purchased June 18, 2020.  The enrollee must be a Plan member at the time the drug is requested or purchased in order for an appeal to be filed. Since you were not enrolled in the Part D Plan when you purchased Chlorthalidone 25 mg purchased March 10, 2020, March 25, 2020, May 7, 2020; Clonazepam 1 mg purchased April 29, 2020;  Hydroxyzine HCL 25 mg purchased March 10, 2020, March 24, 2020; Losartan 25 mg purchased April 29, 2020; Potassium Chloride ER 10 meq purchased March 10, 2020; Telmisartan 40 mg purchased March 10, 2020; and Telmisartan 80 mg purchased March 17, 2020 was requested or purchased, the case is dismissed. You may wish to submit your request for reimbursement for these claims to the Part D Plan that was effective on these dates of service.