Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Ondansetron ODT 4 mg, Truvada 200-300 mg and Isentress 400 mg. The Plan did not grant this request. We received this case to conduct an independent review.Ondansetron ODTMedicare 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 $12 copayment for up to a 30 day supply of a Tier 2 drug purchased in 2019 from a preferred retail pharmacy. Ondansetron ODT is on the Plan's 2019 Formulary and is classified as a Tier 2 drug. 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 Ondansetron ODT 4 mg purchased was purchased for an amount that is less than or equal to the required copayment amount.TruvadaMedicare 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 30% coinsurance for up to a 30 day supply of a Tier 5 drug purchased in 2019 from a preferred retail pharmacy. Truvada is on the Plan's 2019 Formulary and is classified as Tier 5 drug. 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 Truvada 200-300 mg purchased was purchased for an amount that is less than or equal to the required copayment amount.IsentressIn this case, the records show that when Isentress 400 mg was purchased, the claim straddled both the initial coverage stage and the coverage gap stage of the Part D benefit. An enrollee is responsible for the applicable copayment/coinsurance amount for each phase a claim straddles.Documentation provided by the Plan shows that the total cost for Isentress 400 was $1653.12. The initial coverage phase requires a 30% coinsurance copayment for this drug and day supply purchased. The Plan documentation also shows that there was $884.34 remaining in the initial coverage phase which is subject to the 30% coinsurance. The $884.34 is subtracted from the total cost of the drug. This left a remaining total drug cost owed of $730.34.This remaining balance ($730.34) was subject to the coverage gap copayment/coinsurance amount of 25%. 25% of the remaining balance is $192.20. The total of the two figures owed during each benefit phase (initial coverage stage and coverage gap stage) is $457.50. 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 Isentress 400 mg purchased on October 22, 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 contract. Therefore, our decision is the Plan is not required to provide reimbursement for Ondansetron ODT 4 mg, Truvada 200-300 mg and Isentress 400 mg.