Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for Part B drugs. We decided that the Plan does not have 
to waive the cost sharing for radiation therapy, chemotherapy administration, subcutaneous port insertion, and 
specialist office visits.  
 
You asked the Plan to waive the cost sharing for all items and services. You say that you only get social 
security and do not have a pension. You also say it takes you awhile to pay some of your bills. The Plan says 
that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to waive the cost sharing for Part B drugs.  
 
The Plan asked you to pay 20% coinsurance for Part B drugs received from July 1, 2021, to November 11, 
2021. According to Medicare, Part B drug codes J7030, J7050, J1644, J1756, and J3420 are considered 
packaged codes/services. Therefore, these codes are not separately payable. We decided that the Plan has to 
waive the cost sharing for the Part B drugs provided from July 1, 2021, to November 11, 2021.  
 
We also decided that the Plan does not have to waive the cost sharing for radiation therapy, 
chemotherapy administration, subcutaneous port insertion, and specialist office visits. 
 
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 in-network administration of Part B drugs. The Plan contract also says that enrollees must 
pay a $60 copayment for in-network radiation therapy. The Plan contract also says that enrollees must pay a 
$20 copayment for an in-network specialist office visit. The Plan contract also says that enrollees must pay a 
$295 copayment for in-network outpatient surgery at an outpatient hospital. 
 
You have been asked to pay $33.48, which is 20% coinsurance of the allowed amount for chemotherapy 
administration received on August 26, 2021 ($167.39 allowed amount x 20% coinsurance = $33.48). 
Chemotherapy administration falls within the Medicare Part B Prescription Drug benefit category.  
 
You have also been asked to pay a $60 copayment for each radiation therapy treatment from July 6, 2021, to 
August 19, 2021. Radiation therapy falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. You have also been asked to pay a $20 copayment for each specialist office visit 
from August 12, 2021, to November 11, 2021. A specialist office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visit benefit category. You have also been asked to pay a $295 copayment 
for a subcutaneous port insertion on July 11, 2021. A subcutaneous port insertion falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost sharing for radiation therapy, 
chemotherapy administration, subcutaneous port insertion, and specialist office visits provided from July 1, 
2021, to November 11, 2021. 
 
 
 
 
  
 
 
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.