Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay the coinsurance and copayment for the part B drugs, and 
outpatient services provided on September 9, 2021.  
You asked the Plan to pay the coinsurance and copayment for the part B drugs and outpatient services. You say 
that your maximum out-of-pocket was fulfilled and the Plan should pay for these services. The Plan denied 
your request. The Plan says the enrollee did not hit there MOOP prior to the date of service. Therefore, the 
proper cost share was applied for the services. 
 
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 the yearly in-network 
MOOP is $3,900. Prior to the date of service $1,685.67 was paid towards the yearly in-network MOOP of 
$3,900. The remaining balance to pay of the yearly in-network MOOP was $2,214.33 ($3,900 yearly in-
network MOOP - $1,685.67 paid towards MOOP). 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Medicare-covered 
chemotherapy drug and the administration of that drug. The first charged total amount was $176.46 with a 
coinsurance of $35.29 ($176.46 total amount x 20% coinsurance). The second charged total amount was 
$294.96 with a coinsurance of $58.99 ($294.96 total amount x 20% coinsurance). The third total amount was 
$8,308.44 with a coinsurance of $1,556.80 which is less than a 20% coinsurance amount of $1661.68 
($8,308.44 total amount x 20% coinsurance). The total amount of coinsurance for the date of service was 
$1,651.08 ($35.29 coinsurance + $58.99 coinsurance + $1,556.80 coinsurance).  
 
Your contract with the Plan also clearly says that you must pay a $250 copayment for Medicare-covered 
surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other 
facility charges and physician or surgical charges. The total amount allowed was $117.64 which is less than the 
copayment amount of $250. Therefore, only $117.64 was charged as the copayment amount. 
 
The total cost share amount for the date of service was $1,768.72 ($1,651.08 coinsurance + $117.64 
copayment) which is less than the $2,214.33 that was left of the yearly in-network MOOP. Therefore, the 
enrollee did not hit there MOOP during the date of service. 
 
You have been asked to pay a $1,661.68 coinsurance for the part B drugs and a $117.64 copayment for 
outpatient services. The part B drugs falls within the Medicare Part B Prescription Drugs benefit category. The 
outpatient services falls within the 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. Therefore, we decided that the Plan does not have to pay the 
coinsurance and copayment for the part B drugs, and outpatient services provided on September 9, 2021.