Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Twinrix vaccine and its administration fee (01/31/2020, 02/29/2020, 08/03/2020) and Boostrix vaccine and its administration fee (01/31/2020). The Plan did not grant this request. We received this case to conduct an independent review.In this case, the records show that when Twinrix was purchased on 01/31/2020, 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 $47.00 copayment amount for this drug and day supply purchased. The Plan documentation also shows that there was $104.50 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 $18.50. This remaining balance was subject to the initial coverage stage $47.00 amount. $47.00 of the remaining balance is $18.50 which is less than or equal to the required copayment. The total of the two figures owed during each benefit phase (deductible and initial coverage) is $123.00 The record shows that the enrollee was charged an amount that is less than or equal to the required copayment for each phase the claim was processed in. The cost of Twinrix was applied to your yearly true out-of-pocket (TrOOP) costs.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, the Plan is not required to provide additional payment and/or reimbursement for Twinrix vaccine and its administration fee.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 Twinrix vaccine and its administration fee (02/29/2020, 08/03/2020) and Boostrix vaccine and its administration fee (01/31/2020). 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 Twinrix vaccine and its administration fee (02/29/2020, 08/03/2020) and Boostrix vaccine and its administration fee (01/31/2020).