Appeal type: Drugs
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for chemotherapy drugs and administration services. You say that 
you are requesting review of these bills. The Plan says that the cost-sharing amounts you are being charged are 
correct. 
 
We decided that the Plan has to reduce the cost-sharing for administration services .  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $35 copayment for specialist administration of 
chemotherapy drugs. A summary of the cost-sharing amounts you have been asked to pay and the amounts you 
may be asked to pay based on your contract with the Plan is shown below: 
 
Date of 
Service 
Service 
Provided 
Allowed 
Amount 
Cost-Share 
Per Contract 
Cost-Share 
Charged by 
Plan 
Your Cost-
Share 
Responsibility 
September 
13, 2021 
Chemotherapy 
Administration 
$37.33 $35 copayment $35 $35 
September 
13, 2021 
Chemotherapy 
Administration 
$175.59 $35 copayment $35.12 $0 
September 
13, 2021 
Chemotherapy 
Administration 
$36.49 $35 copayment $7.30 $0 
September 
20, 2021 
Chemotherapy 
Administration 
$19.89 $35 copayment $19.89 $19.89 
September 
20, 2021 
Chemotherapy 
Administration 
$175.59 $35 copayment $35.12 $15.11 
September 
27, 2021 
Chemotherapy 
Administration 
$19.89 $35 copayment $19.89 $19.89 
September 
27, 2021 
Chemotherapy 
Administration 
$175.59 $35 copayment $35.12 $15.11 
September 
27, 2021 
Chemotherapy 
Administration 
$36.49 $35 copayment $7.30 $0 
October 4, 
2021 
Chemotherapy 
Administration 
$19.89 $35 copayment $19.89 $19.89 
October 4, 
2021 
Chemotherapy 
Administration 
$175.59 $35 copayment $35.12 $15.11 
Total    $249.75 $140 
 
The Plan says you must pay $249.75 for chemotherapy administration visits. Based on the Plan contract, 
however, you cannot be asked to pay more than $140, which is $35 copayment per visit for chemotherapy 
administration. Therefore, we decided that the Plan has to reduce the cost-sharing for administration services 
from $249.75 to $140.  
 
We also decided that the Plan does not have to waive the cost-sharing for chemotherapy drugs and 
administration 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 that you must pay 20% 
coinsurance for chemotherapy drugs and $35 copayment for specialist administration services. A summary of 
your cost-sharing amounts is shown on the following page: 
   
Date of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-
Share 
Responsibility 
September 13, 2021 Administration $249.41 $35 copayment $35 
September 13, 2021 Rituximab $5,906.40 20% coinsurance $1,181.28 
September 13, 2021 Diphenhydramine $1.03 20% coinsurance $0.21 
September 13, 2021 Methylprednisolone $8.56 20% coinsurance $1.71 
September 20, 2021 Administration $195.48 $35 copayment $35 
September 20, 2021 Diphenhydramine $1.03 20% coinsurance $0.21 
September 20, 2021 Rituximab $5,906.40 20% coinsurance $1,181.28 
September 27, 2021 Administration $231.97 $35 copayment $35 
September 27, 2021 Diphenhydramine $1.03 20% coinsurance $0.21 
September 27, 2021 Rituximab $5,906.40 20% coinsurance $1,181.28 
October 4, 2021 Administration $195.48 $35 copayment $35 
October 4, 2021 Rituximab $5,906.40 20% coinsurance $1,181.28 
October 4, 2021 Diphenhydramine $0.95 20% coinsurance $0.19 
Total    $4,867.65 
 
Therefore, we decided that the Plan does not have to waive the cost-sharing for chemotherapy drugs and 
administration services. 
 
Therefore, we decided that the Plan has to reduce your total cost-sharing amount from $4,977.40 to $4,867.65. 
 
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.