Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover or provide reimbursement for multiple drugs. The Plan did not grant this request. We received this case to conduct an independent review.Azathioprine and MycophenolateYou asked the Plan to cover or provide reimbursement for multiple drugs. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B of Medicare for that individual. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to a beneficiary who has received an organ transplant, provided the beneficiary receiving the drug was enrolled in Medicare Part A at the time of the organ transplant.The case record indicates that Azathioprine and Mycophenolate is needed for an organ transplant. According to Medicare enrollment records, the enrollee was determined to be entitled to Medicare Part A coverage at the time of the transplant. Thus, the transplant is considered a Medicare covered transplant and Azathioprine and Mycophenolate is eligible for coverage under Medicare Part B. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, our decision is that Part D Plan is not required to cover Azathioprine and Mycophenolate.This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.Multiple DrugsMedicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The enrollee will generally have to pay the full cost when the prescription is filled. The enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost.In this case, the record shows that you received Aspirin 81 mg DR, Sodium Bicarbonate, Sucralfate, Loperamide, Labetalol, Novolog, Cefpodoxime, SMZ-TMP, BD Pen Needle, Ondansetron, Nystatin, Pantoprazole, Amlodipine, Linezolid, Oxycodone/APAP, Basaglar, Ranitidine, and Sevelamer. You submitted a request for reimbursement with a copy of an itemized bill. However, the record does not include proof of payment in full. The bill submitted reflects a balance amount due of $890.62. The Plan's criteria for reimbursement have not been met. Therefore, our decision is the Plan is not required to cover or provide reimbursement for Aspirin 81 mg DR, Sodium Bicarbonate, Sucralfate, Loperamide, Labetalol, Novolog, Cefpodoxime, SMZ-TMP, BD Pen Needle, Ondansetron, Nystatin, Pantoprazole, Amlodipine, Linezolid, Oxycodone/APAP, Basaglar, Ranitidine, and Sevelamer.GrievanceYour complaint that you were unaware that your prescriptions would require a copayment or coinsurance 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).