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 Hydrocodone-Acetaminophen, Hydrocodone-Homatropine Syrup, Oxycodone-Acetaminophen, Morphine Sulfate ER, Amoxicillin-Clavulanate, Prednisone, Guaifenesin, Fentanyl 50 mcg/hr Patch, Hydromorphone, Nystatin, Sucralfate, Prochlorperazine and Ondansetron HCL purchased between May 30, 2019 and November 2, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Medicare 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 a low-income subsidy (LIS), copay level 1, effective October 1, 2019 through December 31, 2019. For copay level 1, an enrollee is required to pay $3.40 for Tier 1 Generic or Preferred Multi-source drugs and $8.50 for Tier 2 Any other drug.In this case, you purchased Amoxicillin-Clavulanate 875-125 mg, Guaifenesin 400 mg, Prednisone 10 mg, Fentanyl 50 mcg/hr Patch and Hydromorphone 2 mg purchased October 16, 2019; Oxycodone-Acetaminophen 10-325 mg purchased October 25, 2019; Nystatin 100,000 units/mL, Sucralfate 1 gm, Prochlorperazine 10 mg and Ondansetron HCL 8 mg purchased October 28, 2019; and Morphine Sulfate ER 30 mg purchased November 2, 2019. The record shows that these drugs were purchased for an amount that is more than the required LIS copayment amount. Proof of payment was provided for each drug and date of service listed. The Plan's documentation indicates the pharmacies used are in-network pharmacies. The Plan did not provide any reason why these claims should not be processed at this time.The case record indicates that the Plan did not provide 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 required to process and provide reimbursement for Amoxicillin-Clavulanate 875-125 mg, Guaifenesin 400 mg, Prednisone 10 mg, Fentanyl 50 mcg/hr Patch and Hydromorphone 2 mg purchased October 16, 2019; Oxycodone-Acetaminophen 10-325 mg purchased October 25, 2019; Nystatin 100,000 units/mL, Sucralfate 1 gm, Prochlorperazine 10 mg and Ondansetron HCL 8 mg purchased October 28, 2019; and Morphine Sulfate ER 30 mg purchased November 2, 2019.We are dismissing the request for Hydrocodone-Acetaminophen 10-325 mg purchased May 30, 2019, June 28, 2019, July 29, 2019 and August 29, 2019 from; Hydrocodone-Homatropine Syrup and Oxycodone-Acetaminophen purchased September 26, 2019; Morphine Sulfate ER purchased September 27, 2019 from; and Amoxicillin-Clavulanate and Prednisone purchased September 30, 2019 according to Medicare rules. The enrollee must be a Plan member at the time the drug is requested or purchased in order for an appeal to be filed. The documentation shows you were not enrolled with this Plan at the time of these purchases. Since you were not enrolled in the Part D Plan when Hydrocodone-Acetaminophen 10-325 mg purchased May 30, 2019, June 28, 2019, July 29, 2019 and August 29, 2019 from; Hydrocodone-Homatropine Syrup and Oxycodone-Acetaminophen purchased September 26, 2019; Morphine Sulfate ER purchased September 27, 2019 from; and Amoxicillin-Clavulanate and Prednisone purchased September 30, 2019 were purchased, the request is dismissed.