Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide additional reimbursement for Zolpidem Tartrate. The Plan did not grant this request. We received this case to conduct an independent review.   Medicare rules require a Part D Plan to issue a coverage decision or a redetermination decision within the specified timeframes. If the Plan does not make a timely decision, this is considered a denial. In these circumstances, the Plan is required to forward the coverage request or the redetermination request to the Part D QIC. The case record indicates multiple requests were submitted to the Plan. The Plan did not properly process these requests to move the case forward to the next appeal level. Therefore, the applicable time frames have been exceeded, and the Part D QIC has jurisdiction to process this case.   Our decision is the Plan is not required to provide additional reimbursement for Zolpidem Tartrate purchased on June 24, 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 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 Zolpidem and indicated on the date of the purchase the insurance company had not yet approved prior authorization or coverage for Zolpidem. It appears the Plan provided reimbursement for this fill once they completed and approved your request for a prior authorization and 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 because coverage had not yet been approved by the Plan.  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.  Since the claim was rejected because coverage had not yet been approved at the time of the purchase 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 Zolpidem Tartrate purchased on June 24, 2020.  Please note, whether the Plan should provide a one-time exception to their reimbursement rules given the circumstances of this case is a grievance. A grievance is any complaint or dispute, other than one that involves a coverage 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.    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). Since your complaint involves a grievance, the Part D Plan must review this part of your complaint under the Plan's grievance procedures. At this time, you should contact the Plan for information on how to proceed with having this part of your complaint reviewed under the Plan's grievance procedures.