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 Budesonide EC 3 mg purchased February 20, 2020. The Plan did not grant this request. We received this case to conduct an independent review.In this case, you requested coverage and reimbursement for Budesonide EC 3 mg purchased February 20, 2020 that was already covered by GoodRx. According to the GoodRx terms of use found on their website (https://www.goodrx.com/medicare): Medicare is supposed to make your prescription drugs affordable. But, as many seniors know, some drugs are still expensive, and some aren't covered at all. And, of course, there's the infamous donut hole.GoodRx makes it easy to compare your Medicare co-pays against GoodRx coupon prices to see which can save you more. Keep in mind that you cannot use GoodRx and Medicare at the same time. However, you can use GoodRx instead of government-funded programs, such as Medicare of Medicaid, to pay for your prescription medications. When you decided to use GoodRx you acknowledged and agreed that GoodRx will be treated as the primary pay or with respect to medications that you have selected to purchase through the Blink Services. Thus, Budesonide EC 3 mg purchased February 20, 2020 is not eligible for reimbursement by Part D. Therefore, it is our decision that the Plan is not required to cover or provide reimbursement for Budesonide EC 3 mg purchased February 20, 2020.Please note: the documentation submitted with your request indicates you would like the amount you paid out of pocket for the Budesonide EC 3 mg purchased February 20, 2020 applied to your TrOOP (True Out of Pocket expenses). Although the Plan is not required to provide reimbursement for Budesonide EC 3 mg purchased February 20, 2020, the Plan may be able to apply the amount you paid to your yearly expenses. According to Chapter 4, Section 3.2 of the Plan's 2020 Evidence of Coverage:Make sure we have the information we need. There are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 5, Section 2 of this booklet.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs:- When you purchase a covered drug at a network pharmacy at a special price or using a discount card that is not part of our plan's benefit.- When you made a copayment for drugs that are provided under a drug manufacturer patient assistance program.- Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances.MAXIMUS Federal does not have the ability to do this for the plan. You may wish to discuss this further with the Plan.