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 Incruse Ellipta purchased March 6, 2017, January 4, 2018, February 3, 2018, January 8, 2019 and February 4, 2019. The Plan did not grant this request. We received this case to conduct an independent review.March 6, 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 March 2017. A request for coverage/reimbursement was not submitted to the Plan until May 2020. As a result, the claim was 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 Incruse Ellipta purchased March 6, 2017.January 4, 2018, February 3, 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 copay level 2, effective January 1, 2018 through December 31, 2019. For copay level 2, an enrollee is required to pay $1.25 and $3.70 in 2018 and $1.25 and $3.80 copayments in 2019.In this case, the Plan provided documentation that Incruse Ellipta was purchased for $3.70 in 2018 and $3.80 in 2019. The record shows that Incruse Ellipta was purchased for an amount that is less than or equal to the required LIS copayment amount.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 Incruse Ellipta purchased January 4, 2018, February 3, 2018, January 8, 2019 and February 4, 2019.Please note: this decision only addresses Incruse Ellipta purchased March 6, 2017, January 4, 2018, February 3, 2018, January 8, 2019 and February 4, 2019 due to the Plan only forwarding the March 6, 2017, January 4, 2018, February 3, 2018, January 8, 2019 and February 4, 2019 dates of service for Incruse Ellipta. If you would like to dispute other dates of service for Incruse Ellipta you may wish to contact the Plan. There are other drugs that are being reviewed under different appeals. You will receive different letters for each drug.