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 Jardiance 25 mg purchased January 24, 2019, February 21, 2019, May 14, 2019, July 29, 2019 and November 1, 2019. The Plan did not grant this request. We received this case to conduct an independent review.January 24, 2019 Date of ServiceMedicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. In this case, documentation in the record shows that the enrollee was in the deductible stage when Jardiance was purchased on January 24, 2019. During the deductible stage, the Plan requires that the enrollee pay the full cost of Tier 3, Tier 4 and Tier 5 drugs purchased in 2019 before the Plan would pay a share of the cost. Jardiance purchased January 24, 2019 was on the Plan's 2019 formulary and was classified as a Tier 3 drug. The Plan provided documentation showing that this claim was covered by the Plan at the time of purchase, and that the full cost of the purchase in dispute was applied to the required deductible amount.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is not required to provide reimbursement for Jardiance purchased January 24, 2019.February 21, 2019 Date of ServiceThe records show that when Jardiance was purchased on February 21, 2019, the claim straddled both the deductible stage and the initial coverage stage of the Part D benefit. An enrollee is responsible for the full cost of covered drugs until the deductible amount of $350 is satisfied. The initial coverage phase requires a $141 copayment amount for this drug and day supply purchased. The Plan documentation shows that there was $94.22 left in the deductible phase of coverage. This amount is subtracted from the total cost of the drug. This left a remaining total drug cost owed of $447.87. This remaining balance was subject to the initial coverage stage $141 copayment amount. The total of the two figures owed during each benefit phase (deductible and initial coverage) is $235.22. The record shows that the enrollee was charged an amount that is less than or equal to the required copayment for each phase the claim was processed in. The cost of Jardiance purchased February 21, 2019 was applied to your yearly true out-of-pocket (TrOOP) costs.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, the Plan is not required to provide additional payment and/or reimbursement for Jardiance purchased February 21, 2019.May 14, 2019, July 29, 2019 and November 1, 2019 Date of ServiceMedicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost. The Plan required a $141 copayment amount for up to a 90 day supply of a Tier 3 drug purchased from a standard in-network retail pharmacy in 2019. In this case, the Plan provided documentation showing that these claims were purchased as 90 day supplies and covered by the Plan at the time of purchase. The record shows that Jardiance purchased May 14, 2019, July 29, 2019 and November 1, 2019 was purchased for an amount that is less than or equal to the required copayment amount.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 Jardiance purchased May 14, 2019, July 29, 2019 and November 1, 2019.