Yes, because the transaction is at a pharmacy and the amount of the transaction is an exact multiple that does not exceed five times the maximum copayment for prescriptions, the debit can be treated as substantiated without further review or documentation.
Automatic substantiation. A debit or credit amount can be treated as substantiated if it exactly matches the plan's copayment amount for the particular product or service. For example, if an employee debits $10 for a doctor's visit under a plan with a $10 copayment for each doctor visit, the debit can be treated as automatically substantiated.
Moreover, automatic substantiation applies if a debit or credit charge is an exact multiple of a plan copayment (e.g., a debit of $30 for three prescriptions under a plan with a $10 copayment for prescription drugs). The copayment match substantiation method can be used if a plan has multiple copayments for the same product or service (e.g., different copayments for generic and non-generic drugs).
Automatic substantiation applies only as long as the exact multiple does not exceed five times the maximum copayment. If the dollar amount of a debit or credit charge exceeds five times the copayment, the transaction must be treated as conditional pending additional confirmation.
Source: IRS Notice 2006-69, I.R.B. 2006-31, July 31, 2006.