Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide additional reimbursement for Irbesartan 300 mg, Carvedilol 6.25 mg, Verapamil 240 mg, Allopurinol 100 mg, Atorvastatin 40 mg and Tamsulosin 0.4 mg from the Pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.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. Pursuant to guidelines issued by the Centers for Medicare and Medicare Services (CMS), as of February 1, 2014, the Plan has enacted a policy in which an enrollee is responsible for the difference between the cash price paid and the Plan's contracted negotiated rate for a drug for any purchases made at an in-network pharmacy that are not submitted online electronically through the pharmacy.In this case, the Plan approved coverage for Irbesartan 300 mg, Carvedilol 6.25 mg, Verapamil 240 mg, Allopurinol 100 mg, Atorvastatin 40 mg and Tamsulosin 0.4 mg purchased from the Pharmacy. The Plan calculated reimbursement by using their contracted negotiated rate as the total cost for the drugs and subtracting the required copayment amount. Thus, the Plan charged the enrollee the difference between the cash price paid and the Plan's contracted negotiated rate for this drug. The Plan is permitted to calculate reimbursement this way for in-network pharmacy purchases not run online electronically per Medicare rules.The case record indicates that the Plan provided coverage and calculated reimbursement in accordance with Medicare law and rules. Therefore, our decision is the Plan is not required to provide additional reimbursement for Irbesartan 300 mg, Carvedilol 6.25 mg, Verapamil 240 mg, Allopurinol 100 mg, Atorvastatin 40 mg and Tamsulosin 0.4 mg purchased from your Pharmacy.Please note: When you purchased these drugs from the Pharmacy, the Pharmacy did not run your Medicare insurance. Therefore, you should reach out to the pharmacy to reconcile your claim for any additional reimbursement you feel applicable.Whether the Plan should provide a one-time exception to their reimbursement rules given the circumstances of this case regarding a mistaken loss of coverage is a grievance. A grievance is any complaint or dispute, other than one that involves a coverage 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.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). Since your complaint involves a grievance, the Part D Plan must review this part of your complaint under the Plan's grievance procedures. At this time, you should contact the Plan for information on how to proceed with having this part of your complaint reviewed under the Plan's grievance procedures.