Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing and pay for immune globulin infusions, 
infusion administration services, and self-administered drugs provided from February 26, 2020 to April 23, 
2020. 
 
You asked the Plan to waive the cost-sharing and pay for Part B drugs, drug administration services, and self-
administered drugs. You say that these bills are in error and you have not been given an explanation of what 
these charges are for. The Plan denied your request. The Plan says the cost-sharing amounts you are being 
charged are correct. The Plan also says that the denial of payment for the self-administered drugs is correct, 
because these drugs are not covered by Medicare Part B and you should seek reimbursement under your 
Medicare Part D prescription drug benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that Medicare Part B generally does not pay for self-
administered drugs. Your contract with the Plan clearly says that you must pay 20% coinsurance for Part B 
drugs and $295 copayment for administration services in an outpatient hospital facility. For each of the 
outpatient hospital services, you have been asked to pay the allowed amount of the charge because this is less 
than the $295 copayment for administration services in an outpatient hospital. Your cost-sharing amounts are 
shown in the table below: 
 
Date of Service 
Service(s) 
Provided 
Allowed 
Amount(s) 
Cost-Share Per 
Contract 
Your Cost-
Sharing 
Responsibility 
February 26, 2020 Immune Globulin $399.21 20% coinsurance $79.84 
February 26, 2020 Immune Globulin $1,596.84 20% coinsurance $319.37 
February 26, 2020 Infusion Services 
$170.72 
$35.41 
$35.41 
$295 copayment $241.54 
March 26, 2020 Immune Globulin $399.21 20% coinsurance $79.84 
March 26, 2020 Immune Globulin $1,596.84 20% coinsurance $319.37 
March 26, 2020 Infusion Services 
$170.72 
$35.41 
$35.41 
$295 copayment $241.54 
April 23, 2020 Immune Globulin $1,987.50 20% coinsurance $397.50 
April 23, 2020 Infusion Services 
$170.72 
$35.41 
$35.41 
$295 copayment $241.54 
Total    $1,920.54 
 
Your total cost-sharing obligation is therefore $1,920.54.  
 
 
 
You have been asked to pay 20% coinsurance for Part B drugs and $295 copayment for administration services 
for Part B drugs, drug administration services, and self-administered drugs. Part B drugs, drug administration 
services, and self-administered drugs falls within the "Medicare Part B Prescription Drugs" and "Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers" benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Additionally, the self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to waive the cost-sharing and pay for 
immune globulin infusions, infusion administration services, and self-administered drugs provided from 
February 26, 2020 to April 23, 2020.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.