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 Albuterol, Atorvastatin, Amlodipine, Carisoprodol, Freestyle Lite Meter, Freestyle Lite Test Strips, Famotidine, Hydrocortisone, Loratadine, Metformin, OneTouch Delica Lancing Device, Ranitidine, Acetaminophen-Codeine, Clonazepam, Cyclobenzaprine, Fluticasone, Fluconazole, Lyrica, Oxybutynin ER, Ondansetron, Polyethylene Glycol 3350, Pregabalin, Synjardy and Ventolin purchased between January 13, 2016 and November 25, 2019 from the pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.We are dismissing the request for reimbursement for Cyclobenzaprine purchased January 13, 2016, February 24, 2016 and April 7, 2016 and Ondansetron purchased August 5, 2016. 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 Cyclobenzaprine purchased January 13, 2016, February 24, 2016 and April 7, 2016 and Ondansetron purchased August 5, 2016 were purchased, these claims are dismissed and the Plan is not required to provide reimbursement.Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. You asked the Part D Plan to provide coverage for test strips. Diabetic test strips are a medical supply that is specifically excluded from Part D coverage by Medicare law. Therefore, our decision is the Part D Plan is not required to cover or provide reimbursement for Freestyle Lite Test Strips purchased June 20, 2019, July 8, 2019, August 2, 2019, September 6, 2019, October 7, 2019 and November 22, 2019 from the pharmacy. Please contact the Plan for more information regarding reimbursement of the test strips under the Part B benefit.Medicare Part D only covers items that meet the definition of a Part D drug. The requested item does not meet the definition of a Part D drug because it either does not require a prescription, it is not approved by the FDA for safety and effectiveness, or it is otherwise excluded. Therefore, our decision is the Plan is not required to cover or provide reimbursement for Freestyle Lite Meter purchased June 20, 2019.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 an LIS, copay level 2, effective January 1, 2019 through December 31, 2019. For copay level 2, an enrollee is not subject to a deductible and is required to pay copayment amounts of $1.25 for generic drugs and $3.80 for brand name drugs. The enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost.The record does not include proof of payment for Amlodipine purchased July 24, 2019, August 23, 2019 and November 25, 2019; Acetaminophen-Codeine purchased July 24, 2019 and August 23, 2019; Clonazepam purchased July 25, 2019 and August 23, 2019; Cyclobenzaprine purchased July 9, 2019, August 8, 2019 and November 25, 2019; Fluticasone purchased July 24, 2019 and August 23, 2019; Famotidine purchased November 25, 2019; Hydrocortisone purchased July 24, 2019 and August 23, 2019; Loratadine purchased August 23, 2019 and November 25, 2019; Metformin purchased July 8, 2019 and August 8, 2019; OneTouch Delica Lancing Device purchased August 23, 2019; Oxybutynin ER purchased July 31, 2019, August 23, 2019 and November 25, 2019; Pregabalin purchased August 23, 2019; Ranitidinepurchased July 24, 2019 and Ventolin purchased July 24, 2019. Because the record does not include proof of payment in full for these claims we cannot review the request for reimbursement and the Plan is not required to provide reimbursement for these claims.The following list of claims did include proof of payment. Additionally, the Plan provided proof that the claims were covered at the time of purchase and they were purchased for an amount that is less than or equal to the required LIS copayment:- Albuterol purchased August 23, 2019, September 23, 2019 and October 22, 2019- Atorvastatin purchased November 22, 2019- Acetaminophen-Caffeine purchased January 15, 2019, February 15, 2019, March 22, 2019, April 23, 2019, May 22, 2019, June 25, 2019, September 23, 2019, October 23, 2019 and November 22, 2019- Clonazepam purchased January 15, 2019, March 22, 2019, April 23, 2019, May 22, 2019, June 25, 2019, September 23, 2019, October 23, 2019 and November 22, 2019- Cyclobenzaprine purchased January 15, 2019, February 15, 2019, March 12, 2019, April 6, 2019, May 6, 2019, June 7, 2019, September 23, 2019 and October 22, 2019- Fluticasone purchased January 15, 2019, February 15, 2019, March 12, 2019, May 20, 2019, June 20, 2019 September 23, 2019 and October 22, 2019- Fluconazole purchased November 22, 2019- Lyrica purchased April 4, 2019, May 20, 2019 and June 20, 2019- Oxybutynin ER purchased January 15, 2019, February 15, 2019, March 12, 2019, July 1, 2019, September 23, 2019 and October 22, 2019- Ondansetron purchased March 12, 2019- Polyethylene Glycol 3350 purchased January 15, 2019, February 15, 2019 and March 12, 2019- Pregabalin purchased September 23, 2019, October 22, 2019 and November 22, 2019- Synjardy purchased October 23, 2019 and November 22, 2019- Ventolin purchased 3350 purchased January 15, 2019, February 15, 2019 and March 12, 2019The 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 the drugs and dates of service in the bulleted list above.Lastly, you requested reimbursement for Carisoprodol 350 mg purchased May 10, 2018. A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, there is proof of payment for this claim. However, the record shows you paid full price for this claim due to not obtaining a formulary exception approval from the Plan prior to purchasing. The Plan did not provide any documentation that a formulary exception has since been approved for the 2018 coverage year. Therefore, the Plan is not required to cover or provide reimbursement for Carisoprodol 350 mg purchased May 10, 2018.