Persius/hicric huggingface dataset:
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluconazole 150 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved, and the amount charged for date of fill January 15, 2021 was applied to the enrollee's deductible at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the deductible cost share stage for date of fill January 15, 2021. Therefore, we determined the amount charged to the enrollee was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluconazole 150 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill February 3, 2021 and June 11, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage for the tier 2 drug for date of fill February 3, 2021 and in the coverage gap cost share stage for date of fill June 11, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 100 milligram capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill February 3, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage when this tier 2 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibuprofen 600 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill April 7, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibuprofen 600 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill, August 4, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Iron 240 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and the amounts charged for dates of fill February 4, 2021, May 22, 2021, and August 4, 2021 were charged copayments correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage for date of fill February 4, 2021, the coverage gap cost share stage for date of fill May 22, 2021, and the coverage gap/catastrophic cost share stage for date of fill August 4, 2021. Therefore, we determined the copay amounts charged to the enrollee were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine Sodium 50 microgram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill May 22, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill July 1, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill June 22, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill March 27, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meclizine Hydrochloride 12.5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill March 17, 2021 and August 9, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage when this tier 2 drug was purchased on March 17, 2021 and in the coverage gap/catastrophic coverage cost share stage on purchase date August 9, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methenamine Hippurate 1 gram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill March 1, 2021, April 30, 2021, and June 28, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage for date of fill March 1, 2021 and the coverage gap cost share stage when this tier 3 drug was purchased on dates of fill April 30, 2021 and June 28, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate 50 milligram extended release 24 hour tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill February 3, 2021, April 27, 2021, and July 13, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage for date of fill February 3, 2021 and the coverage gap cost share stage when this tier 2 drug was purchased on dates of fill April 27, 2021 and July 13, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mupirocin 2 percent ointment prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill April 16, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage for date of fill April 16, 2021 when this tier 2 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mupirocin 2 percent ointment prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill July 19, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 2 drug was purchased on date of fill July 19, 2021. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mupirocin 2 percent ointment prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill February 3, 2021, April 16, 2021, and August 4, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage for date of fill February 3, 2021 and the coverage gap cost share stage when this tier 2 drug was purchased on dates of fill April 16, 2021 and August 4, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolin 70/30 100 unit/milliliter suspension prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill May 26, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 3 drug was purchased for date of fill May 26, 2021. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolin 70/30 100 unit/milliliter suspension prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved. The enrollee was in the deductible cost share stage for part of the cost of the drug and crossed over into the initial coverage stage for the remaining amount at the point of sale for date of fill January 21, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the deductible/initial coverage stages when this tier 3 drug was purchased. Therefore, we determined the deductible and copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolin 70/30 100 unit/milliliter suspension prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill February 13, 2021, March 23, 2021, April 26, 2021, and July 12, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage for dates of fill February 13, 2021 and March 23, 2021, and the coverage gap cost share stage when this tier 3 drug was purchased on dates of fill April 26, 2021 and July 12, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.