Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for the chemotherapy administration and the medical supplies and has to reduce the cost share for the pharmacy charges. We decided that the Plan does not have to waive the cost share for the pharmacy charges.
You asked the Plan to waive the cost share for the chemotherapy administration, the medical supplies, and the pharmacy charges. You say that you had already met your maximum out-of-pocket amount and you should not be responsible for this charge The Plan says that your maximum out-of-pocket amount had not been met by December 17, 2019.
We decided that the Plan has to waive the cost share for the chemotherapy administration and the medical supplies and has to reduce the cost share for the pharmacy charges.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance).
The Plan says that you must pay $212.34 for the chemotherapy administration. Based on the plan contract, however, you cannot be asked to pay more than a $0 copayment for the chemotherapy administration. The records show that you were billed for chemotherapy administration which is considered a physician service.
Therefore, we decided that the Plan has to reduce the copayment for the chemotherapy administration from a $212.34 to a $0 copayment.
Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for medical supplies. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay for medical supplies. The Plan contract lists surgical supplies as a covered benefit but does not clearly list a copayment or coinsurance amount enrollees should expect to pay. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.
The Plan says that you must pay $4.18 for the medical supplies. Based on the plan contract, however, you cannot be asked to pay more than a $0 copayment for the medical supplies. Therefore, we decided that the Plan has to reduce the copayment for the medical supplies from $4.18 to $0.
The records show that you were charged the allowed amounts for the pharmacy charges. The Plan says that you must pay $3.72 for the pharmacy charges. Based on the plan contract, however, you cannot be asked to pay more than $1.54 for the pharmacy charges. Therefore, we decided that the Plan has to reduce the cost for the pharmacy charges from $3.72 to $1.54 coinsurance.
We also decided that the Plan does not have to waive the cost share for the pharmacy charges.
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 the pharmacy charges. Therefore, we decided that the Plan does not have to waive the cost share for the pharmacy charges.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.