Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Levemir purchased. The Plan did not grant this request. We received this case to conduct an independent review.this case, the records show that when Levemir was purchased, 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 $250 is satisfied. The initial coverage phase requires a $141 copayment amount for this drug and day supply purchased (the record shows an 80 day supply was purchased). The Plan documentation shows that there was $250 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 $375.51. This remaining balance was subject to the initial coverage stage copayment amount of $141. The total of the two figures owed during each benefit phase (deductible and initial coverage) is $391. 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 Levemir purchased was applied to your yearly true out-of-pocket (TrOOP) costs.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 $141 copayment amount for up to a 90 day supply of a Tier 3 drug when purchased from a preferred retail pharmacy in 2020. 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 Levemir was purchased or 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 Plan contract. Therefore, the Plan is not required to provide additional payment and/or reimbursement for Levemir purchased.Please note: Your complaint regarding the pharmacy and Plan providing coverage for an 80 day supply instead of a 60 day supply is a grievance. 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).You may also wish to contact your prescriber to discuss how the script is written (as a 30, 60, 80 or 90 day supply).