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 Triamcinolone 0.1% Cream purchased April 30, 2020, Dutasteride 0.5 mg purchased May 1, 2020, Myrbetriq ER 25 mg purchased May 19, 2020 and June 15, 2020, Diclofenac 1% Gel purchased May 1, 2020. 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.DutasterideThe Plan required a $100 copayment for up to a 30 day supply of a Tier 4 drug purchased in 2020 from an in-network pharmacy. Dutasteride 0.5 mg is on the Plan's 2020 formulary and is classified as a Tier 4 drug. In this case, the record shows Dutasteride purchased May 1, 2020 was initially covered at the time of purchase. However, the Plan provided documentation that the claim has since been reversed. The Plan provided documentation that the pharmacy used was an in-network, standard pharmacy. The Plan did not provide any reason why the claims should not be covered at this time. However, the record shows you only paid $18.42 which is less than required copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Dutasteride purchased May 1, 2020; however, the Plan is required to apply the amount you paid to your TrOOP (true out of pocket expenses) for the 2020 coverage year.Diclofenac 1% GelThe Plan required a $47 copayment for up to a 30 day supply of a Tier 3 drug purchased in 2020 from an in-network pharmacy. Diclofenac 1% Gel is on the Plan's 2020 formulary and was classified as a Tier 2 drug. In this case, the record shows that Diclofenac 1% Gel purchased May 1, 2020 was initially covered at the time of purchase. However, the Plan provided documentation that the claim has since been reversed. The Plan provided documentation that the pharmacy used was an in-network, standard pharmacy. The Plan did not provide any reason why the claims should not be covered at this time. However, the record shows you only paid $36 which is less than the required copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Diclofenac 1% Gel purchased May 1, 2020; however, the Plan is required to apply the amount you paid to your TrOOP (true out of pocket expenses) for the 2020 coverage year.Triamcinolone 0.1% CreamThe Plan required a $7 copayment for up to a 30 day supply of a Tier 2 drug purchased in 2020 from an in-network pharmacy. Triamcinolone 0.1% Cream is on the Plan's 2020 formulary and was classified as a Tier 2 drug. A request for reimbursement was submitted to the Plan. 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 Triamcinolone 0.1% Cream was purchased on April 30, 2020 for $6.65 which is less than the required copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Triamcinolone 0.1% Cream purchased April 30, 2020.Myrbetriq ERThe Plan required a $100 copayment for up to a 30 day supply of a Tier 4 drug purchased in 2020 from an in-network pharmacy. Myrbetriq ER 24 mg is on the Plan's 2020 formulary and is classified as Tier 4 drug. A request for reimbursement was submitted to the Plan. 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 Myrbetriq ER 25 mg was purchased May 19, 2020 and June 15, 2020 for $100 each which is less than the required copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Myrbetriq ER 25 mg purchased May 19, 2020 and June 15, 2020.