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 Tadalafil 5 mg tablet purchased September 16, 2019, October 18, 2019 and December 3, 2019. 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 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.In this case, you submitted a request for reimbursement to the Plan for Tadalafil purchased from the pharmacy on September 16, 2019, October 18, 2019 and December 3, 2019 and indicated on the date of purchase the insurance company had denied coverage. It appears the Plan provided reimbursement for this fill once they completed and approved your request for coverage, however reimbursement was provided based on the Plan's negotiated contract rate. As indicated by the enrollee's appeal request it appears this claim was run by the pharmacy on the date of purchase and it was rejected due to needing coverage approval.For cash purchases made at in-network pharmacies, the enrollee is responsible for the difference between the cash price and the Plan's negotiated price, except for circumstances in which a pharmacy's or payer's system is offline at the time of purchase, or in which there is evidence of an enrollment-related error or other a sponsor error that limited the enrollee's access to the negotiated price.It appears that this is a situation in which the Plan's policy of charging the enrollee the difference between the cash price paid and the Plan's contracted negotiated rate for the drug is applicable. Therefore, it is our decision that the Plan is not required to provide additional reimbursement for Tadalafil purchased from the pharmacy on September 16, 2019, October 18, 2019 and December 3, 2019.Your complaint regarding the policy to charge the difference between the cash price paid and the Plan's contracted negotiated rate and request for an exception to this policy 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).