Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide additional reimbursement for Moxifloxacin 0.5% Eye Drops and Durezol 0.5% Eye Drops purchased at the pharmacy. 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. If you pay the full cost of a prescription drug out-of-pocket or if you find you have paid more than you expected to pay under the Plan's coverage rules, you can ask the Plan to pay you back. When submitting a request for reimbursement, the Plan requires that you submit your receipt documenting the payment you have made along with your reimbursement request.In this case, you submitted a paid receipt for Moxifloxacin 0.5% Eye Drops and Durezol 0.5% Eye Drops purchased at the pharmacy. The Plan provided reimbursement for these fills but stated that you were responsible for the difference between the cash price paid and the Plan's negotiated contract rate for the drug because the pharmacy did not automatically submit your claims online to be processed by the Plan. The Plan stated that the pharmacy is a network pharmacy. The record indicates that you purchased Moxifloxacin 0.5% Eye Drops and Durezol 0.5% Eye Drops out of pocket. The policy for an enrollee to be responsible for the difference between the cash price paid and the Plan's contracted negotiated rate for a drug for purchases made at in-network pharmacies that are not automatically run through the Plan's online claims processing system is limited to those situations in which online claims processing is available at the time of purchase but is not utilized. Since you submitted a receipt showing full price for this prescription, it appears that this is a situation in which the Plan's policy of charging the enrollee the difference between the cash price paid and the Plan's contracted negotiated rate for the drug is applicable. Therefore, it is our decision that the Plan is not required to provide additional reimbursement for Moxifloxacin 0.5% Eye Drops and Durezol 0.5% Eye Drops purchased at the pharmacy.In addition, your complaint regarding the fact that you should have received these necessary eye drops as part of service for your surgery and disputes regarding the physician billing and your credit score being affected are all grievances. A grievance is any complaint or dispute, other than one that involves a coverage determination or at-risk determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan. Grievance procedures are separate and distinct from appeal procedures. Medicare defines a coverage determination as (1) a decision not to provide or pay for a Part D drug, (2) failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee, (3) a decision concerning an exceptions request, or (4) a decision on the amount of cost-sharing for a drug. (42 CFR ??423.560, 423.564(b), 423.566(b)).Since your complaint involves a grievance, the Part D Plan must review this complaint under the Plan's grievance procedures. Each Part D Plan must provide meaningful procedures for timely hearing and resolving grievances between enrollees and the Part D Plan (or any other entity or individual through whom the Part D Plan provides covered benefits under any Part D Plan it offers). At this time, you should contact the Plan for information on how to proceed with having this complaint reviewed under the Plan's grievance procedures. 42 CFR Section 423.564(a).