Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Synthroid 137 mcg, Entecavir 0.5 mg and Compound RX from the Pharmacy and clinic. In addition, you asked the Plan to provide reimbursement for Amlodipine 5 mg, Warfarin 2 mg, Losartan Potassium 50 mg, Furosemide 20 mg, Omeprazole 40 mg, Alfuzosin 10 mg, Finasteride 5 mg, Potassium Chloride 10 MEQ purchased at your pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Synthroid 137 mcg purchased at your pharmacy and Entecavir 0.5 mg and Compound RX purchased at your pharmacy:Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. In this case, documentation in the record shows that you were in the deductible stage when Synthroid 137 mcg, Entecavir 0.5 mg and Compound RX were purchased from the Pharmacy and clinic. 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 2020 before the Plan would pay a share of the cost. Synthroid 137 mcg was on the Plan's 2020 formulary and was classified as a Tier 3 drug. Entecavir 0.5 mg and Compound RX were on the Plan's 2020 formulary and were classified as Tier 4 drugs. 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 Synthroid 137 mcg, Entecavir 0.5 mg and Compound RX purchased from the Pharmacy and clinic.Amlodipine 5 mg, Warfarin 2 mg, Losartan Potassium 50 mg, Furosemide 20 mg, Omeprazole 40 mg, Alfuzosin 10 mg, Finasteride 5 mg and Potassium Chloride 10 MEQ purchased through your pharmacy:Medicare 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 copayment for Tier 1 of $45.00 per 90 day supply and Tier 2 copayment of $60.00 for 90 day supply purchased from a standard mail order in 2020. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Amlodipine 5 mg, Warfarin 2 mg, Losartan Potassium 50 mg, Furosemide 20 mg, Omeprazole 40 mg, Alfuzosin 10 mg, Finasteride 5 mg, Potassium Chloride 10 MEQ were 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 Amlodipine 5 mg, Warfarin 2 mg, Losartan Potassium 50 mg, Furosemide 20 mg, Omeprazole 40 mg, Alfuzosin 10 mg, Finasteride 5 mg, Potassium Chloride 10 MEQ purchased at your pharmacy.Amlodipine 5 mg, Warfarin 2 mg, Losartan Potassium 50 mg, Furosemide 20 mg, Omeprazole 40 mg, Alfuzosin 10 mg, Finasteride 5 mg, Potassium Chloride 10 MEQ, Ranitidine 300 mg, Lactulose 10 mg/15 ml, Synthroid 137 mcg and Entecavir 0.5 mg purchased from your pharmacy:We are dismissing this portion of your request. We received your letter asking for an appeal of the Plan's unfavorable determination for Amlodipine 5 mg, Warfarin 2 mg, Losartan Potassium 50 mg, Furosemide 20 mg, Omeprazole 40 mg, Alfuzosin 10 mg, Finasteride 5 mg, Potassium Chloride 10 MEQ, Ranitidine 300 mg, Lactulose 10 mg/15 ml, Synthroid 137 mcg and Entecavir 0.5 mg from the pharmacy. Medicare rules do not allow us to review this case until you have completed the appeal process with the Plan. You may request a Reconsideration appeal with us after the Plan issues an unfavorable Redetermination. You may wish to submit this request to the Plan at this time.In addition, your complaint regarding obtaining a credit or returning medications 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).