Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemotherapy drug injections, the Part B
injections, and their administrations provided on November 12, 2019 and December 24, 2019.
You asked the Plan to waive the cost share for the chemotherapy drug injections, the Part B injections, and
their administrations. You say that you expected the provider to be in-network. The Plan denied your request.
The Plan says you have been charged the correct cost sharing amount.
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 20%
coinsurance for each in-network Medicare-covered chemotherapy drug and the administration of that drug,
20% coinsurance for each in-network Medicare-covered Part B drug, and a $275 copayment for the drug
administration or infusion services.
You have been asked to a total of $4,021.55 for the chemotherapy drug injections, the Part B injections, and
their administrations. the chemotherapy drug injections and the Part B injections fall within the "Medicare Part
B Prescription Drugs" benefit category. The drug administration falls within the each in-network Medicare-covered
Part B drug. Additionally, for the administration of that drug, you will "Outpatient Surgery and Other
Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit
category. See chart below.
Date of Service Service Allowed Amount Coinsurance/Copayment Member
Liability
November 12, 2019 Drug
administration
$68.98 $275 $68.98
November 12, 2019 Drug
administration
$43.73 $275 $43.73
November 12, 2019 Chemo
administration
$68.98 20% $13.80
November 12, 2019 Chemo
administration
$332.93 20% $66.59
November 12, 2019 Chemo
administration
$68.98 20% $13.80
November 12, 2019 Part B drug $79.33 20% $15.87
November 12, 2019 Chemo drug $9,877.80 20% $1,975.56
November 12, 2019 Chemo drug $5,071.46 20% $1,014.29
November 12, 2019 Chemo drug $486.30 20% $97.26
December 24, 2019 Drug
administration
$68.98 $275 $68.98
December 24, 2019 Drug
administration
$43.73 $275 $43.73
December 24, 2019 Chemo
administration
$68.98 20% $13.80
December 24, 2019 Chemo
administration
$332.93 20% $66.59
December 24, 2019 Chemo
administration
$68.98 20% $13.80
December 24, 2019 Part B drug $79.33 20% $15.87
December 24, 2019 Chemo drug $9,877.80 20% $188.90 - This is
where you met
your maximum
out-of-pocket
amount
December 24, 2019 Chemo drug $5,071.46
20% $0
Date of Service Service Allowed Amount Coinsurance/Copayment Member
Liability
December 24, 2019 Chemo drug $486.30 20% $0
Total $3,721.55
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. Therefore, we decided that
the Plan does not have to waive the cost share for the chemotherapy drug injections, the Part B injections, and
their administrations provided on November 12, 2019 and December 24, 2019.