Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Januvia 25 mg. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules require a Part D Plan to issue a coverage decision or a redetermination decision within the specified timeframes. If the Plan does not make a timely decision, this is considered a denial. In these circumstances, the Plan is required to forward the coverage request or the redetermination request to the Part D QIC. The case record indicates multiple requests were submitted to the Plan to review for reimbursement of the claim. The Plan did not properly process these requests to move the case forward to the next appeal level. Therefore, the applicable time frames have been exceeded, and the Part D QIC has jurisdiction to process this case.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.In this case, the documentation shows you purchased a 30 day supply from a mail-order pharmacy. You state you should have been charged a 30 day copayment, but instead you were charged a 90 day copayment amount. According to chapter 6, section 5.2 of the Plan's 2020 Evidence of Coverage, the Plan does not allow separate pricing for up to a 30 day supply of drugs on Tiers 1 through 4 when purchased from a mail-order pharmacy. According to chapter 6, section 5.4 of the Plan's 2020 Evidence of Coverage, the Plan required a $131 copayment for up to 90 day supply of a Tier 3 drug purchased in 2020 from a mail-order pharmacy. Januvia 25 mg is on the Plan's 2020 formulary and is classified as a Tier 3 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 Januvia 25 mg, was purchased as a 30 day supply from a mail-order pharmacy and was purchased for an amount that is less than or equal to the required copayment amount for up to a 90 day supply. 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 Januvia 25 mg.Please note: your complaint also involves a grievance due to the fact that there is no pricing for up to a 30 day supply for Tier 1 through 4 drugs purchased from a mail-order pharmacy and the fact that you were charged for a 90 day supply instead of a 30 day supply.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).