Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the medications, specialist services, and 
physical therapy (PT) services rendered from April 10, 2019 to March 2, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that the cost sharing is a financial 
hardship. The Plan denied your request. The Plan says the cost sharing was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for chemotherapy and all other drugs covered under Medicare Part B, a $25 copayment for 
Medicare-covered physical therapy and speech therapy services, a $25 copayment for Medicare-covered 
specialist services, and a $50 copayment for x-rays. 
 
Review of the file shows that you received chemotherapy on April 10, 2019. You have been asked to pay a 
20% coinsurance for these services, for a total of $243.48. These services fall within the chemotherapy and all 
other drugs covered under Medicare Part B benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan.  
 
The file shows that you received PT services for five dates of service from July 17, 2019 to July 31, 2019. You 
have been asked to pay a $25 copayment per date of service for these services, for a total of $125. These 
services fall within the Medicare-covered physical therapy and speech therapy services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. 
 
The file shows that you received specialist services on July 29, 2019 and August 12, 2019. You have been 
asked to pay a $25 copayment per date of service for these services, for a total of $50. These services fall 
within the specialist services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. 
 
The file shows that you received a Medicare Part B drug injection for three dates of service from July 29, 2019 
to August 12, 2019. You have been asked to pay a 20% coinsurance per date of service for these services, for a 
total of $585.06. These services fall within the chemotherapy and all other drugs covered under Medicare Part 
B benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan.  
 
The file shows that you received injection and specialist services on September 16, 2019. You have been asked 
to pay a $25 copayment for the specialist services and a 20% coinsurance for the injection, for a total of $2.62. 
These services fall within the specialist services and the chemotherapy and all other drugs covered under 
Medicare Part B benefit categories. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. 
 
The file shows that you received specialist services on October 29, 2019 and November 5, 2019. You have 
been asked to pay a $25 copayment per date of service for these services, for a total of $50. These services fall 
within the specialist services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. 
 
The file shows that you received specialist services on March 2, 2020. Per the contract with the Plan, there is a 
$25 copayment for Medicare-covered specialist services. However, the Medicare allowed amount for these 
services was $3.84. Given that the allowed amount was less than the $25 copayment, you have been asked to 
pay $3.84 for these services. 
 
The file shows that you received a knee x-ray on March 2, 2020. Per the contract with the Plan, there is a $50 
copayment for Medicare-covered specialist services. However, the Medicare allowed amount for these services 
was $21.16. Given that the allowed amount was less than the $50 copayment, you have been asked to pay 
$21.16 for these services. 
 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the medications, specialist services, and 
physical therapy (PT) services rendered from April 10, 2019 to March 2, 2020.