Appeal type: Prescription Drug
Decision: 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 Losartan Potassium 100 mg purchased February 1, 2020 and February 28, 2020, Hydrochlorothiazide 12.5 mg purchased February 1, 2020 and February 28, 2020 and Atorvastatin 10 mg purchased March 2, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription drug out-of-pocket or if you find you have paid more than you expected to pay under the Plan's coverage rules, you can ask the Plan to pay you back. When submitting a request for reimbursement, the Plan requires that you submit your receipt documenting the payment you have made along with your reimbursement request.In this case, the enrollee purchased Losartan Potassium 100 mg purchased February 1, 2020 and February 28, 2020, Hydrochlorothiazide 12.5 mg purchased February 1, 2020 and February 28, 2020 and Atorvastatin 10 mg purchased March 2, 2020. The enrollee paid the full cost at the time of purchase. Per Plan documentation full price was paid, out of pocket because Medicare had not provided correct, up to date information for this enrollee's coverage. This caused the pharmacy to reject coverage and payment, causing a COB issue. The Plan indicates, information has been updated and the Plan is now correctly listed as the enrollee's primary insurance. The Plan also indicates the price the enrollee paid is less than the required copayment amounts. However, based on the documentation, the enrollee was in the initial coverage limit stage of coverage at the time of each purchase and a standard pharmacy was used. Losartan, Hydrochlorothiazide and Atorvastatin are all Tier 1 drugs on the Plan's 2020 Formulary. The Plan requires a $5 copayment amount for up to a 30 day supply of a Tier 1 drug when purchased from a standard in-network pharmacy and a $15 copayment amount for up to a 90 day supply of a Tier 1 drug when purchased from an in-network pharmacy.The Plan subsequently provided coverage and reimbursement for the purchase(s) in dispute, but indicated that the enrollee was responsible for the difference between the cash price paid and the Plan's contracted/negotiated rate for the drug because the pharmacy did not automatically submit the claim(s) online to be processed by the Plan.The policy for an enrollee to be responsible for the difference between the cash price paid and the Plan's contracted/negotiated rate, for purchases made at in-network pharmacies that are not automatically run through the Plan's online claims processing system, is limited to those situations in which online claims processing is available at the time of purchase but is not utilized due to an error on the enrollee's part, such as failing to present their insurance card when one was available. Since online claims processing was unable to be utilized in this case due to an error on the Plan and/or pharmacy's part, this is a situation in which the Plan's policy of charging the enrollee the difference between the cash price paid and the Plan's contracted/negotiated rate for the drug is not applicable. Therefore, it is our decision that the Plan is required to reprocess and provide any additional reimbursement for Losartan Potassium 100 mg purchased February 1, 2020 and February 28, 2020, Hydrochlorothiazide 12.5 mg purchased February 1, 2020 and February 28, 2020 and Atorvastatin 10 mg purchased March 2, 2020. The reimbursement amount should be the total cash price paid, minus any applicable tiered copayment/coinsurance amount, and minus any reimbursement already provided only.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.