Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for multiple generic prescriptions, including Timolol, Lisinopril-HCTZ, Atorvastatin, Dilt-XR, Hydrochlorothiazide and Diltiazem ER, purchased after you entered the coverage gap stage. The Plan did not grant this request. We received this case to conduct an independent review.In this case, you requested reimbursement for multiple generic prescriptions purchased from preferred retail and mail order pharmacies. The record shows that the Plan provided coverage for these prescriptions at the time of purchase. When the claims for these generic prescriptions were processed, you were in the coverage gap. While in the coverage gap, you are usually required to pay 25% for brand name drugs or 25% for generic drugs.In your request to us, you indicated that you were owed reimbursement because you were charged greater than 25% of the cost of your prescriptions. Receipts were included, as well as documentation of correspondence with the Plan. According to the Plan representative, Tier 1 generic drugs are subject to a $5 copayment amount for a 90-day supply and Tier 2 generic drugs are subject to a $10 copayment amount for a 90-day supply. Your argument is that this information is not actually in the Plan's EOC, and you are owed reimbursement for overpayment while in the coverage gap stage.Per page 134 of the Plan's 2020 EOC, under the column labelled Stage 3: Coverage Gap Stage: Our Plan offers some drug coverage in the Coverage Gap Stage for drugs on Tier 1 & 2. You pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 25% of the price for generic drugs on all other tiers.Please note that the EOC does indicate that you still have some drug coverage while in the coverage gap stage for drugs on Tier 1 and 2, and the 25% coinsurance for generic prescriptions applies to drugs on all other tiers. This means that the same rules that applied for Tier 1 and Tier 2 drugs in the initial coverage stage apply for these drugs while you are in the coverage gap. You still have full coverage for these prescriptions, and the Plan is able to offer you the drugs on this level at the preferred rate they have negotiated with the pharmacy.Typically, when an enrollee enters the coverage gap stage, the cost of prescriptions increases. This is because you no longer have the same coverage with the Plan during this period. When you are in the initial coverage stage and shop at a preferred location, the Part D Plan is able to offer you a better price because the insurance plans negotiate for better rates with the pharmacies. This is why the cost is greater when you purchase drugs from non-preferred or out of network pharmacies: The Plan does not have the same negotiated rate at these locations. Similarly, when you enter the coverage gap stage, your drug coverage with the Plan changes and often your cost goes up.As an example, if we look at the Atorvastatin tablets purchased, your receipt shows that you paid $1.40 for a 90-day supply. By looking at your receipt, it appears that the Plan paid $0.00 and you paid 100% of the cost for this drug. However, the true cost of this drug from the pharmacy (the price you would pay without insurance) is $519.06 for a 90-day supply. Because the Plan is still able to cover this drug while you are in the coverage gap, you only pay $1.40. If this drug was not covered by the Plan while you were in the coverage gap, you would be responsible for 25% of the full cost of the drug, or $129.77. Because you still have coverage of generic drugs on Tier 1 and Tier 2 while in the coverage gap, and Atorvastatin is a Tier 1 drug on your Plan's 2020 formulary, you still get the favorable Plan contracted rate from the pharmacy.According to the table on page 140 of the Plan's EOC, a 90-day supply of a generic drug on Tier 1, when purchased from a preferred retail or preferred mail-order, is subject to a $5 copayment amount. Drugs on Tier 2 that are purchased from a preferred retail or mail-order are subject to a $10 copayment amount. In 2020, the Plan covered Atorvastatin, Hydrochlorothiazide, Timolol and Lisinopril-HCTZ with a Tier 1 copayment. Dilt-XR and Diltiazem were covered on Tier 2.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. 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 the generic prescriptions were each purchased for an amount that is less than or equal to the required copayment amount.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 the generic prescriptions when you entered the coverage gap stage.Please note that the miscommunication and/or misleading information from the customer service representative regarding your copayment/coinsurance amounts is a grievance. 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.