Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Atorvastatin purchased February 21, Cephalexin purchased March 3, Duloxetine purchased March 4, Fluticasone purchased March 4, Solifenacin purchased March 4, and Tramadol purchased February 25, 2020, from the pharmacy. The Plan did not grant this request. 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 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. Regarding the request for reimbursement for Atorvastatin purchased February 21, 2020: the Plan requires a $45 copayment for up to a 90-day supply of a Tier 1 drug purchased from a standard retail pharmacy in 2020. Atorvastatin is on the Plan's 2020 formulary and is classified as a Tier 1 drug. A request for reimbursement was submitted to the Plan. The Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Atorvastatin was purchased for an amount that is less than or equal to the required copayment amount. Regarding the request for reimbursement for Cephalexin purchased March 3, Fluticasone purchased March 4, and Tramadol purchased February 25, 2020: the Plan requires a $20 copayment for up to a 30-day supply of a Tier 2 drug purchased from a standard retail pharmacy in 2020. Cephalexin, Fluticasone, and Tramadol are on the Plan's 2020 formulary and are classified as Tier 2 drugs. A request for reimbursement was submitted to the Plan. The Plan provided documentation showing that these claims were covered by the Plan at the time of purchase. The record shows that Cephalexin, Fluticasone, and Tramadol were purchased for an amount that is less than or equal to the required copayment amount.Regarding the request for reimbursement for Duloxetine purchased March 4, 2020: the Plan requires a $47 copayment for up to a 30-day supply of a Tier 3 drug purchased from a standard retail pharmacy in 2020. Duloxetine is on the Plan's 2020 formulary and is classified as a Tier 3 drug. A request for reimbursement was submitted to the Plan. The Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Duloxetine was purchased for an amount that is less than or equal to the required copayment amount. Regarding the request for reimbursement for Solifenacin purchased March 4, 2020: the Plan requires a $100 copayment for up to a 30-day supply of a Tier 4 drug purchased from a standard retail pharmacy in 2020. Solifenacin is on the Plan's 2020 formulary and is classified as a Tier 4 drug. A request for reimbursement was submitted to the Plan. The Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Solifenacin 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 for all drugs in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Atorvastatin purchased February 21, Cephalexin purchased March 3, Duloxetine purchased March 4, Fluticasone purchased March 4, Solifenacin purchased March 4, and Tramadol purchased February 25, 2020, from the pharmacy.