Appeal type: Prescription Drug
Decision: Partially Favorable

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 Tamsulosin HCL, Albuterol HFA, Atorvastatin, Losartan Potassium, Gabapentin, Levothyroxine, Furosemide, Fluticasone Propionate, Basaglar Kwikpen, Metoprolol Succinate ER, Wixela 250-50 Inhub, Amlodipine Besylate, Metformin HCL, Cyclopentolate 1% and Vitamin D2 purchased March 21, 2019 through October 29, 2019. The Plan did not grant this request. We received this case to conduct an independent review.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 annual deductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and a reduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extent of reduction in these benefits depends on an individual's income and resources. According to enrollment records from the Centers for Medicare & Medicaid Services (CMS), you were determined to be entitled to a low-income subsidy (LIS), copay leve1 1 from July 1, 2019 through July 31, 2019 and copay level 2 from August 1, 2019 through December 31, 2019. For copay level 1 you were responsible for a $3.40 copayment amount for Cost Sharing Tier 1 Generic or Preferred Multi-source drugs and an $8.50 copayment amount for Cost Sharing Tier 2 Any other drug. For copay level 2 you were responsible for a $1.25 copayment amount for Generic or Preferred Multi-source drugs and a $3.80 copayment amount for Cost Sharing Tier 2 Any other drug.Favorable DecisionIn this case, you purchased several drugs from July 29, 2019 through October 1, 2019. Proof of payment was submitted with your request to the Plan. The record shows that Omeprazole DR 20 mg and Tamsulosin HCL 0.4 mg purchased July 29, 2019; Albuterol HFA 90 mcg purchased August 1, 2019; Atorvastatin 20 mg, Losartan Potassium 50 mg, Gabapentin 300 mg, Levothyroxine 25 mcg, Furosemide 20 mg, Omeprazole DR 20 mg and Fluticasone Propionate 50 mcg purchased August 18, 2019; Basaglar Kwikpen 100 unit/mL purchased October 11, 2019; Metoprolol Succinate ER 50 mg, Tamsulosin HCL 0.4 mg and Atorvastatin 20 mg purchased October 29, 2019; and Wixela 250-50 Inhub purchased October 1, 2019 were purchased for amounts that are more than required LIS copayment amount.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract and with the LIS benefit to which you were entitled. Therefore, our decision is the Plan is required to process and provide reimbursement for Omeprazole DR 20 mg and Tamsulosin HCL 0.4 mg purchased July 29, 2019; Albuterol HFA 90 mcg purchased August 1, 2019; Atorvastatin 20 mg, Losartan Potassium 50 mg, Gabapentin 300 mg, Levothyroxine 25 mcg, Furosemide 20 mg, Omeprazole DR 20 mg and Fluticasone Propionate 50 mcg purchased August 18, 2019; Basaglar Kwikpen 100 unit/mL purchased October 11, 2019; Metoprolol Succinate ER 50 mg, Tamsulosin HCL 0.4 mg and Atorvastatin 20 mg purchased October 29, 2019; and Wixela 250-50 Inhub purchased October 1, 2019.Unfavorable DecisionAmlodipine Besylate 5 mg, Metformin HCL 1,000 mg purchased August 18, 2019 and Metformin HCL 1,000 mg purchased October 29, 2019 were purchased for amounts that are less than or equal to the required copayment amount. The case record indicates that the Plan did provide coverage in accordance with the Part D Plan contract and with the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required to provide reimbursement for Amlodipine Besylate 5 mg, Metformin HCL 1,000 mg purchased August 18, 2019 and Metformin HCL 1,000 mg purchased October 29, 2019.Medicare law excludes certain drugs from Part D coverage. Vitamin D2 1.25 mg purchased July 30, 2019is one of those excluded drugs because it is a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Vitamin D2 1.25 mg. Therefore, the Plan is not required to cover or provide reimbursement for Vitamin D2 1.25 mg purchased July 30, 2019.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.