Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for outpatient services provided from June 8, 
2021, to July 6, 2021. 
 
You asked the Plan to waive the cost sharing for the outpatient services. You say that these services are 
experimental and that you should not be required to pay for them. The Plan denied your request. The Plan says 
the cost sharing applied is correct. 
 
  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 drugs covered under Medicare Part B. The contract also show that you must pay a $45 for 
injections as a hospital outpatient. The table below shows that you are being charged a $5 copayment for some 
and 20% coinsurance for some, which is less than $45. 
 
 
 
Date of Service Service Allowable 
Amount 
Cost Share 
per Contract 
Your Cost-Share 
Responsibility 
Total 
June 8, 2021 PHARMACY 
ESKETAMINE <= 56MG 
OFFICE VISIT 
INJECTION 
$7.80 
$368.40 
$94.64 
$247.20 
20% coins. 
20% coins. 
$5 copay 
$45 copay 
$1.56 
$73.68 
$5 
$45 
 
 
 
$125.24 
June 10, 2021 ESKETAMINE <= 56MG 
ESKETAMINE >56MG 
INJECTION 
OFFICE VISIT 
$1,105.20 
$770.40 
$247.20 
$94.64 
20% coins. 
20% coins. 
$45 copay 
$5 copay 
$221.04 
$154.08 
$45 
$5 
 
 
 
$425.12 
June 15, 2021 PHARMACY 
PHARMACY 
ESKETAMINE <= 56MG 
INJECTION 
OFFICE VISIT 
$7.80 
$24.60 
$736.80 
$247.20 
$94.64 
20% coins. 
20% coins. 
20% coins. 
$45 copay 
$5 copay 
$1.56 
$4.92 
$147.36 
$45 
$5 
 
 
 
 
$203.84 
June 17, 2021 PHARMACY 
PHARMACY 
ESKETAMINE >56MG 
INJECTION 
OFFICE VISIT 
$24.60 
$7.80 
$1,105.20 
$247.20 
$94.64 
20% coins. 
20% coins. 
20% coins. 
$45 copay 
$5 copay 
$4.92 
$1.56 
$221.04 
$45 
$5 
 
 
 
 
$277.52 
June 22, 2021 ESKETAMINE >56MG 
INJECTION 
OFFICE VISIT 
PHARMACY 
$1,105.20 
$247.20 
$94.64 
$7.80 
20% coins. 
$5 copay 
$5 copay 
20% coins. 
$221.04 
$5 
$5 
$1.56 
 
 
 
$232.60 
June 24, 2021 PHARMACY 
ESKETAMINE >56MG 
INJECTION 
OFFICE VISIT 
$7.80 
$1,105.20 
$247.20 
$64.01 
20% coins. 
20% coins. 
$45 copay 
$5 copay 
$1.56 
$221.04 
$45 
$5 
 
 
 
$272.60 
June 28, 2021 OFFICE VISIT 
ESKETAMINE >56MG 
IV INFUSION 
$64.01 
$1,105.20 
$81.60 
$5 copay 
20% coins. 
$5 copay 
$5 
$221.04 
$5 
 
 
$231.04 
June 29, 2021 ESKETAMINE >56MG 
PHARMACY 
$1,105.20 
$7.80 
20% coins. 
20% coins. 
$221.04 
$1.56 
 
$222.60 
July 1, 2021 PHARMACY 
ESKETAMINE >56MG 
INJECTION 
IV THERAPY 
OFFICE VISIT 
$7.80 
$1,105.20 
$81.60 
$54.60 
$64.01 
20% coins. 
20% coins. 
20% coins. 
$45 copay 
$5 copay 
$1.56 
$221.04 
$16.32 
$45 
$5 
 
 
 
 
$288.92 
July 6, 2021 IV INFUSION 
OFFICE VISIT 
$247.20 
$64.01 
$45 copay 
$5 copay 
$45 
$5 
 
$50 
Total     $2329.48 
 
  You have been asked to pay a 20% coinsurance for the Esketamine and pharmacy visits as a hospital 
outpatient, a $45 copay for IV therapy and infusions as a hospital outpatient, and a $5 copay for office visits 
with your primary care physician. The drug therapy falls within the Outpatient hospital services benefit 
category. The office visits and IV therapy and infusions fall within the Physician/Practitioner services, 
including doctors office visits 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 waive the cost sharing for outpatient 
services provided from June 8, 2021, to July 6, 2021.