Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Elmiron 100 mg purchased January 14, 2020, August 17, 2020 and October 1, 2020. The Plan did not grant this request. We received this case to conduct an independent review.   January 14, 2020  Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. In this case, documentation in the record shows that the enrollee was in the deductible stage when Elmiron 100 mg was purchased on January 14, 2020. During the deductible stage, the Plan requires that the enrollee pay the full cost of Tier 3, Tier 4 and Tier 5 drugs purchased in 2020 before the Plan would pay a share of the cost. Elmiron 100 mg is on the Plan's 2020 formulary and was classified as a Tier 5 drug. The Plan provided documentation showing that this claim was covered by the Plan at the time of purchase, and that the full cost of the purchase in dispute was applied to the required deductible amount.  The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is not required to provide reimbursement for Elmiron 100 mg purchased January 14, 2020.  August 17, 2020  In this case, the records show that when Elmiron 100 mg purchased on August 17, 2020 the claim straddled both the deductible stage and the initial coverage stage of the Part D benefit. An enrollee is responsible for the full cost of covered drugs until the deductible amount $435 is satisfied. The initial coverage phase requires a 25% coinsurance amount for this drug and day supply purchased. In this case, the documentation shows that the total cost of Elmiron purchased August 17, 2020 was $296.47. There was $182.37 remaining in the deductible phase of coverage. This amount is subtracted from the total cost of the drug. This left a remaining total drug cost owed of $114.10. This remaining balance was subject to the initial coverage stage 25% coinsurance amount. 25% of the remaining balance is $28.53. The total of the two figures owed during each benefit phase (deductible and initial coverage) is $210.90. The record shows that the enrollee was charged $182.37, which is less than or equal to the required copayment for each phase the claim was processed in. The cost of Elmiron 100 mg purchased August 17, 2020 was applied to your yearly true out-of-pocket (TrOOP) costs.  October 1, 2020  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. The Plan required a 25% coinsurance amount for up to a 30 day supply of a Tier 5 drug purchased from an in network retail pharmacy. 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 Elmiron 100 mg purchased October 1, 2020 was 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 Elmiron 100 mg purchased October 1, 2020.