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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Prezcobix 800 mg/150 mg purchased January 13, 2017and January 17, 2018 at your pharmacy. The Plan did not grant this request. We received this case toconduct an independent review.January 13, 2017:Medicare law requires that Part D Plans coordinate benefits with SPAPs, other entities providingprescription drug coverage, beneficiaries, and others paying on the beneficiaries' behalf for a period of 3years from the date on which the prescription for a covered Part D drug was filled. This means that claimsfor coverage and reimbursement must be submitted to the Plan within 3 years from the date of purchase. Inthis case, the record shows that the purchase in dispute was made in January 2017. A request forcoverage/reimbursement was not submitted to the Plan until May 2020. As a result, the claim was notsubmitted within the Medicare required timeframe of 3 years or less from the date the drug was filled.Therefore, our decision is that the Plan is not required to provide reimbursement for Prezcobix 800 mg/150mg purchased January 13, 2017 at your pharmacy.January 17, 2018: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 annualdeductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and areduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extentof reduction in these benefits depends on an individual's income and resources. According to enrollmentrecords from CMS, you were determined to be entitled to an LIS,copay level 2, effective January 1, 2018through December 31, 2018. For copay level 2, an enrollee is required to pay a $1.25 and $3.70copayments.In this case, the Plan provided documentation that Prezcobix 800 mg/150 mg was purchased on January 17,2018 for $3.70. The record shows that Prezcobix 800 mg/150 mg was purchased for an amount that is lessthan or equal to the required LIS copayment amount for this date.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract andwith the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required toprovide reimbursement for Prezcobix 800 mg/150 mg purchased on January 17, 2018 at your pharmacy.Please note: this decision only addresses Prezcobix 800 mg/150 mg purchased January 13, 2017 andJanuary 17, 2018 due to the Plan only forwarding the January 13, 2017 and January 17, 2018 dates ofservice for Prezcobix. If you would like to dispute other dates of service for Prezcobix you may wish tocontact the Plan. There are other drugs that are being reviewed under different appeals. You will receiveddifferent letters for each drug.