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 usas required by Medicare rules because it did not make a timely decision. Of note, initially the plan provideddocumentation that claims from both 2018 and 2019 were being submitted to Maximus Federal for review.The Plan later clarified that the 2018 claims were submitted to Maximus in error. Therefore, only the 2019claims were reviewed as a part of this appeal. If you have questions regarding claims from 2018, you maywish to contact the Plan at this time.You asked the Plan to provide reimbursement for Losartan 100 mg, Gabapentin 100 mg and 300 mg,Sulfamethoxazole-Trimethoprim 800-160 mg, Tramadol HCL 50 mg, Fluticasone 50 mcg, Myrbetriq 50mg, Potassium Chloride 20 meq, Diclofenac 1% Gel, Premarin 0.625 mg Cream, Durezol 0.5%, Besivance0.6% Suspension, Prolensa 0.07% and Fluocinolone 0.01% purchased January 15, 2019 through December4, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Initial Coverage LimitMedicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrolleepays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof ofpayment to ask the Plan to pay its share of the cost. The Plan required a $10 copayment for up to a 30 daysupply of a Tier 2 drug purchased in 2019 from an in-network pharmacy and $30 copayment for up to a 90day supply from a standard retail pharmacy. Gabapentin, Sulfamethoxazole-Trimethoprim, Tramadol,Fluticasone and Potassium Chloride were on the Plan's 2019 Formulary and classified as Tier 2 drugs.The Plan required a $45 copayment for up to a 30 day supply of a Tier 3 drug purchased in 2019 from anin-network pharmacy and $135 copayment for up to a 90 day supply from a standard retail pharmacy.Diclofenac 1% Gel, Premarin 0.625 mg Cream, Durezol 0.5% and Durezol were on the Plan's 2019Formulary and classified as Tier 3 drugs.The Plan required a $95 copayment for up to a 30 day supply of a Tier 4 drug purchased in 2019 from anin-network pharmacy and $285 copayment for up to a 90 day supply from a standard retail pharmacy.Besivance 0.6% Suspension, Prolensa 0.07% and Fluocinolone 0.01% were on the Plan's 2019 Formularyand classified as Tier 4 drugs.A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentationshowing that the following claims were covered by the Plan at the time of purchase:Tier 1 drugs:&#61623; Losartan 100 mg purchased September 26, 2019Tier 2 drugs:&#61623; Gabapentin 100 mg purchased January 15, 2019, February 22, 2019, March 20, 2019 andSeptember 26, 2019&#61623; Sulfamethoxazole-Trimethoprim 800-160 mg purchased February 18, 2019&#61623; Tramadol HCL 50 mg purchased September 12, 2019&#61623; Fluticasone 50 mcg purchased September 26, 2019&#61623; Potassium Chloride 20 meq purchased November 5, 2019Tier 3 drugs:&#61623; Diclofenac 1% Gel purchased January 19, 2019&#61623; Premarin 0.625 mg Cream purchased February 14, 2019, February 26, 2019, March 26, 2019 andMay 21, 2019&#61623; Durezol 0.5% purchased April 19, 2019Tier 4 drugs:&#61623; Besivance 0.6% Suspension purchased April 19, 2019&#61623; Prolensa 0.07% purchased April 19, 2019&#61623; Fluocinolone 0.01% purchased September 13, 2019The record shows that you were in the initial coverage limit stage of coverage when you purchased eachdrug in the list above. The documentation shows these drugs were purchased for amounts that is less thanor equal to the required copayment amounts for the day supply purchased and type of pharmacy used foreach claim.Coverage GapIn this case, the enrollee requested reimbursement for Losartan 100 mg purchased December 4, 2019. Therecord shows that the Plan provided coverage for Losartan 100 mg purchased December 4, 2019. When theclaim for Losartan 100 mg was processed, the enrollee was in the coverage gap. While in the coverage gap,the enrollee is required to pay 25% for brand name drugs or 37% for generic drugs. Losartan 100 mg is ageneric drug on Tier 1 of the Plan's 2019 formulary. The amount the enrollee was charged was less than orequal to the required coverage gap copayment. The cost of Losartan 100 mg purchased December 4, 2019was applied to the enrollee's yearly true out-of-pocket (TrOOP) costs. Therefore, our decision is the Plan isnot required to provide reimbursement for Losartan 100 mg purchased December 4, 2019.The documentation shows you attempted to purchase Myrbetriq 50 mg from two different pharmacies onNovember 5, 2019. The Plan reversed one claim and provided documentation a second claim was paid forby the Plan. When claim that was not revered for Myrbetriq 50 mg was processed, the enrollee was in thecoverage gap. While in the coverage gap, the enrollee is required to pay 25% for brand name drugs or 37%for generic drugs. Myrbetriq is a brand drug on Tier 3 of the Plan's 2019 Formulary. The amount theenrollee was charged was less than or equal to the required coverage gap copayment. The cost of Myrbetriq50 mg purchased November 5, 2019 was applied to the enrollee's yearly true out-of-pocket (TrOOP) costs.Therefore, our decision is the Plan is not required to provide reimbursement for Myrbetriq 50 mg purchasedNovember 5, 2019.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 Losartan 100 mg,Gabapentin 100 mg and 300 mg, Sulfamethoxazole-Trimethoprim 800-160 mg, Tramadol HCL 50 mg,Fluticasone 50 mcg, Myrbetriq 50 mg, Potassium Chloride 20 meq, Diclofenac 1% Gel, Premarin 0.625 mgCream, Durezol 0.5%, Besivance 0.6% Suspension, Prolensa 0.07% and Fluocinolone 0.01% purchasedJanuary 15, 2019 through December 4, 2019.