Appeal type: Prescription Drug
Decision: Partially Favorable

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 cover and provide reimbursement for Metformin 500 mg purchased March 23, 2020, Spironolactone 25 mg purchased February 12, 2020, Pravastatin 20 mg purchased February 12, 2020, Losartan HCTZ 100-12.5 mg purchased February 12, 2020, Metoprolol Tartrate 100 mg purchased March 17, 2020, Levothyroxine 112 mcg purchased March 17, 2020, Metformin 500 mg purchased April 21, 2020, Spironolactone 25 mg purchased March 19, 2020 and Metoprolol Tartrate 100 mg purchased May 20, 2020. The Plan did not grant this request. We received this case to conduct an independent review. These were all filled at in network pharmacies.Metformin purchased March 23, 2020, Spironolactone purchased February 12, 2020, Pravastatin purchased February 12, 2020, Losartan HCTZ purchased February 12, 2020, Metoprolol Tartrate purchased March 17, 2020 and Levothyroxine purchased March 17, 2020: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 you can ask the Plan to pay you back. In this case, you purchased Metformin March 23, 2020, Spironolactone February 12, 2020, Pravastatin February 12, 2020, Losartan HCTZ February 12, 2020, Metoprolol Tartrate March 17, 2020 and Levothyroxine March 17, 2020 at your pharmacy. You then submitted a request for reimbursement along with paid receipts to your Plan. The Plan's coverage rules were followed. Therefore, our decision is the Plan is required to process and provide applicable reimbursement for Metformin purchased March 23, 2020, Spironolactone purchased February 12, 2020, Pravastatin purchased February 12, 2020, Metoprolol Tartrate purchased March 17, 2020 and Levothyroxine purchased March 17, 2020.Metformin purchased April 21, 2020, Spironolactone purchased March 19, 2020 and Metoprolol Tartrate purchased May 20, 2020:The Plan says an enrollee may use a network retail pharmacy to fill their prescriptions. The Plan also says for prescriptions written for a 10-day supply or more, the member cannot obtain a refill from a retail pharmacy until 75% of the days supply is used.Based on the information provided in the case record, there is sufficient evidence to conclude that Metformin 500 mg purchased April 21, 2020, Spironolactone purchased March 19, 2020 and Metoprolol Tartrate purchased May 20, 2020 were all refilled too soon. This is because Metformin, Spironolactone and Metoprolol Tartrate were filled as follows: Metformin was filled on March 23, 2020, 90 per 90 days, Spironolactone was filled on February 12, 2020, 90 per 90 days and Metoprolol Tartrate was filled on March 17, 2020, 180 per 90 days. Based on the information provided in the case record, there is sufficient evidence to conclude that Metformin, Spironolactone and Metoprolol Tartrate were refilled too soon. Therefore our decision is the Plan is not required to provide payment for Metformin filled on April 21, 2020, Spironolactone filled on March 19, 2020 and Metoprolol Tartrate filled on May 20, 2020.