Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified time frame. 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 Dorzolamide HCL 2% purchased on November 18, 2019 from Woodland Hills Pharmacy and Dorzolamide-Timolol purchased on December 17, 2019 from Woodland Hills Pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.In this case, the enrollee requested reimbursement for Dorzolamide HCL 2% purchased on November 18, 2019 from Woodland Hills Pharmacy and Dorzolamide-Timolol purchased on December 17, 2019 from Woodland Hills Pharmacy. The record shows that the Plan provided coverage for Dorzolamide HCL 2% purchased on November 18, 2019 from Woodland Hills Pharmacy and Dorzolamide-Timolol purchased on December 17, 2019 from Woodland Hills Pharmacy. When the claim for Dorzolamide HCL 2% purchased on November 18, 2019 from Woodland Hills Pharmacy and Dorzolamide-Timolol purchased on December 17, 2019 from Woodland Hills Pharmacy was processed, the enrollee was in the coverage gap. During the coverage gap stage, for generic drugs, the enrollee pays a $5 Copayment for up to a 30-day supply, a $10 Copayment for a 31 - 60 day supply, or a $15 Copayment for a 60 - 100 day supply at the Plan Pharmacy. The amount the enrollee was charged was less than or equal to the required coverage gap copayment. The cost of Dorzolamide HCL 2% purchased on November 18, 2019 from Woodland Hills Pharmacy and Dorzolamide-Timolol purchased on December 17, 2019 from Woodland Hills Pharmacy 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 Dorzolamide HCL 2% purchased on November 18, 2019 from Woodland Hills Pharmacy and Dorzolamide-Timolol purchased on December 17, 2019 from Woodland Hills Pharmacy.Please note: your complaint regarding your dispute based on being provided with 2 bottles of Dorzolamide 2% drops instead of 3 bottles as a 100 day supply is a grievance. 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).