CMS-10407 CMS-10407_Brst_Cncer
Summary of Benefits and Coverage and Uniform Glossary
CMS-10407_Brst_Cncer.xlsx
Summary of Benefits and Coverage and Uniform Glossary
OMB: 0938-1146
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1146 can be found here:
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Scenario
Provider Types
Sample Care Cost Categories
Overview
Label and AssumptionsScenario
Provider Types
Sample Care Cost Categories
Sheet 1: Label and Assumptions
| Treating breast cancer (lumpectomy, chemotherapy, radiation) |
Instructions to Insurers: Do not modify this tab. The numbers shown here roll up from the Scenario tab. Transfer this label to the Summary of Coverage exactly as shown here. | |
| Sample care costs: | Instructions for HHS: | |
| Office visits & procedures | $2,800 | * HHS to provide this label exactly as they want it to appear on the Summary of Coverage. |
| Radiology | $2,100 | * HHS to reuse existing sample care cost categories unless a new category is required. |
| Laboratory tests | $1,500 | * HHS to specify no more than 11 sample care cost categories as space on the page with 12 point font dictates. |
| Outpatient surgery | $1,900 | * All of these costs roll up from the Scenario tab; HHS to confirm these totals match to the Scenario tab. |
| Chemotherapy | $27,000 | |
| Radiation therapy | $10,500 | |
| Prostheses (wig) | $300 | |
| Pharmacy | $1,100 | |
| Mental health | $2,800 | |
| Total | $50,000 | * This total must match the total on the Scenario tab; HHS to confirm it matches before issuing to insurers. |
| Assumptions | ||
| The following are assumptions that all health plan carriers make to calculate the scenario. | ||
| Standard Assumptions | ||
| These assumptions are standard across all scenarios. (HHS to apply these assumptions regardless of scenario.) | ||
| Costs do not include premiums. | ||
| Condition was not an excluded as a pre-existing condition. | ||
| There are no other medical expenses for any member covered under the plan. | ||
| All care is in-network. No out-of-network charges or any other variation in Sample Care Costs. | ||
| All services occur in same policy period. | ||
| All prior authorizations were obtained. | ||
| All services were deemed medically necessary. | ||
| All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth. | ||
| All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth. | ||
| All medications are covered as generic equivalents if available. | ||
| All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks. | ||
| Special Assumptions | ||
| These assumptions are specific to this scenario only. (HHS to specify special assumptions.) | ||
| [HHS to supply any assumptions that are specific to this scenario] | ||
Sheet 2: Scenario
| Medical Condition: | Breast Cancer | ||||||
| Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into that category in the "Sample care costs" section so that those costs are uniform across all carriers and plans. However, some plans may classify that service under another category. The insurer should apply their cost sharing and benefit features for each policy in order to complete the “You pay” section, but must leave the "Sample care costs" section as is. Examples of cost sharing and benefit features include, but are not limited to: • Payment of services based on the location where they are provided (inpatient, outpatient, office, etc.) • Payment of items as prescription drugs vs. medical equipment Instructions to HHS for Completing the Columns: Date of Service - include Month/Day of service so insurers understand the order in which services are rendered. Do not include year. Diagnosis Code - include the ICD code for each service CPT code - include the CPT code for each service Provider Type - use one of the types listed on the "Provider Types" tab to classify each service by provider Category - use one of the categories listed on the "Sample Care Cost Categories" tab to classify each service so they roll up into the broader cost categories on the "Label and Assumptions" tab Notes - freeform field to include any special notes for that service Allowed Amount - include the total cost for each service that would be owed to providers that insurers will use to calculate cost-sharing CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. |
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| Date of Service | Diagnosis Code | CPT©, HCPCS, or Other Billing Code | Provider Type | Category | Notes | Allowed Amount | |
| Total | 50186.72 | ||||||
| 3-Jan | C50.4 | 99214 | Primary | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 3-Jan | C50.4 | 77057 | Specialist | Radiology | Mammogram Screening | $81.20 | |
| 7-Jan | C50.4 | 99205 | Specialist | Office visits & procedures | Office/Outpatient Visit New | $171.73 | |
| 7-Jan | C50.4 | 77055 | Specialist | Radiology | Mammogram One Breast | $86.64 | |
| 8-Jan | C50.4 | 77059 | Specialist | Radiology | MRI Both Breasts | $787.23 | |
| 10-Jan | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 10-Jan | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 10-Jan | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen Metabolic Panel | $14.87 | |
| 10-Jan | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 14-Jan | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 |
|
| 14-Jan | C50.4 | 19102 | Specialist | Office visits & procedures | BX Breast Percut W/Image | $212.69 | |
| 14-Jan | C50.4 | 76942 | Specialist | Radiology | Echo Guide For Biopsy | $198.08 | |
| 14-Jan | C50.4 | 88307 | Specialist | Laboratory tests | Tissue Exam By Pathologist | $226.28 | |
| 21-Jan | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 31-Jan | C50.4 | 00404 | Specialist | Anesthesia | Anest Surgery of Breast | $395.21 | |
| 31-Jan | C50.4 | 77057 | Specialist | Radiology | Mammogram Screening | $81.20 | |
| 31-Jan | C50.4 | 19290 | Specialist | Outpatient surgery | Place needle wire breast | $159.35 | |
| 31-Jan | C50.4 | 38792 | Specialist | Outpatient surgery | Identify Sentinel Node | $40.43 | |
| 31-Jan | C50.4 | J2250 | Specialist | Outpatient surgery | Inj midazolam hydrochloride | $1.73 | |
| 31-Jan | C50.4 | J3010 | Specialist | Outpatient surgery | Fentanyl citrate injection | $18.53 | |
| 31-Jan | C50.4 | 78195 | Specialist | Outpatient surgery | Lymph System Imaging | $352.68 | |
| 31-Jan | C50.4 | 38525 | Specialist | Outpatient surgery | Biopsy/Removal Lymph Nodes | $424.03 | |
| 31-Jan | C50.4 | 19302 | Specialist | Outpatient surgery | P-Mastectomy W/LN Removal | $867.42 | |
| 31-Jan | C50.4 | 88305 | Specialist | Laboratory tests | Tissue Exam By Pathologist | $106.01 | |
| 31-Jan | C50.4 | 88307 | Specialist | Laboratory tests | Tissue Exam By Pathologist | $226.28 | |
| 31-Jan | C50.4 | 76098 | Specialist | Radiology | X-Ray Exam Breast Specimen | $19.37 | |
| 31-Jan | C50.4 | 88365 | Specialist | Laboratory tests | In Situ Hybridization (FISH) | $165.47 | |
| 31-Jan | C50.4 | 88331 | Specialist | Laboratory tests | Path Consult Intraop 1 Bloc | $91.40 | |
| 31-Jan | C50.4 | 88291 | Specialist | Laboratory tests | Cyto/Molecular Report | $29.29 | |
| 31-Jan | C50.4 | 88361 | Specialist | Laboratory tests | Tumor Immunohistochem/Comput | $151.53 | |
| 31-Jan | C50.4 | 84233 | Specialist | Laboratory tests | Assay Of Estrogen | $90.64 | |
| 31-Jan | C50.4 | 84234 | Specialist | Laboratory tests | Assay Of Progesterone | $91.29 | |
| 31-Jan | C50.4 | 857118 | Pharmacy Retail | Pharmacy | Acetaminophen 500 mg / Hydrocodone bitartrate 7.5 mg, oral tablet | $16.04 | |
| 21-Feb | C50.4 | 99215 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $137.60 | |
| 21-Feb | C50.4 | 78472 | Specialist | Radiology | Gated Heart Planar Single | $252.10 | |
| 21-Feb | C50.4 | 78800 | Specialist | Radiology | Tumor Imaging Limited Area | $187.21 | |
| 21-Feb | C50.4 | A9282 | Alternative Provider | Prostheses (wig) | Wig any type | $265.00 | |
| 23-Feb | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 23-Feb | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion 1 Hr | $146.44 | |
| 23-Feb | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion Addl Hr | $31.26 | |
| 23-Feb | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | Chemo IV Push Sngl Drug | $112.80 | |
| 23-Feb | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | Hydration IV Infusion Init | $57.08 | |
| 23-Feb | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 23-Feb | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 23-Feb | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen Metabolic Panel | $14.87 | |
| 23-Feb | C50.4 | J9000 | Pharmacy Administered | Chemotherapy | Doxorubicin hcl injection | $254.78 | |
| 23-Feb | C50.4 | J9070 | Pharmacy Administered | Chemotherapy | Cyclophosphamide 100 MG inj | $531.88 | |
| 23-Feb | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 23-Feb | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 23-Feb | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 23-Feb | C50.4 | J2060 | Pharmacy Retail | Pharmacy | Lorazepam injection | $4.28 | |
| 23-Feb | C50.4 | J2405 | Pharmacy Retail | Pharmacy | Ondansetron hcl injection | $269.73 | |
| 23-Feb | C50.4 | 854875 | Pharmacy Retail | Pharmacy | Zolipdem tartrate 10 mg oral tablet [Ambien] | $44.50 | |
| 25-Feb | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 1-Mar | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 9-Mar | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 9-Mar | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion 1 Hr | $146.44 | |
| 9-Mar | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion Addl Hr | $31.26 | |
| 9-Mar | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | Chemo IV Push Sngl Drug | $112.80 | |
| 9-Mar | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | Hydration IV Infusion Init | $57.08 | |
| 9-Mar | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 9-Mar | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 9-Mar | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen Metabolic Panel | $14.87 | |
| 9-Mar | C50.4 | J9000 | Pharmacy Administered | Chemotherapy | Doxorubicin hcl injection | $254.80 | |
| 9-Mar | C50.4 | J9070 | Pharmacy Administered | Chemotherapy | Cyclophosphamide 100 MG inj | $531.88 | |
| 9-Mar | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 9-Mar | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 9-Mar | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 11-Mar | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 23-Mar | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 23-Mar | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion 1 Hr | $146.44 | |
| 23-Mar | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion Addl Hr | $31.26 | |
| 23-Mar | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | Chemo IV Push Sngl Drug | $112.80 | |
| 23-Mar | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | Hydration IV Infusion Init | $57.08 | |
| 23-Mar | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 23-Mar | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 23-Mar | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen Metabolic Panel | $14.87 | |
| 23-Mar | C50.4 | J9000 | Pharmacy Administered | Chemotherapy | Doxorubicin hcl injection | $254.80 | |
| 23-Mar | C50.4 | J9070 | Pharmacy Administered | Chemotherapy | Cyclophosphamide 100 MG inj | $531.88 | |
| 23-Mar | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 23-Mar | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 23-Mar | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 23-Mar | C50.4 | J2060 | Pharmacy Retail | Pharmacy | Lorazepam injection | $4.28 | |
| 23-Mar | C50.4 | J2405 | Pharmacy Retail | Pharmacy | Ondansetron hcl injection | $269.73 | |
| 25-Mar | C50.4 | 854875 | Pharmacy Retail | Pharmacy | Zolipdem tartrate 10 mg oral tablet [Ambien] | $44.50 | |
| 25-Mar | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 6-Apr | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 6-Apr | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion 1 Hr | $146.44 | |
| 6-Apr | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion Addl Hr | $31.26 | |
| 6-Apr | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | Chemo IV Push Sngl Drug | $112.80 | |
| 6-Apr | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | Hydration IV Infusion Init | $57.08 | |
| 6-Apr | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 6-Apr | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 6-Apr | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 6-Apr | C50.4 | J9000 | Pharmacy Administered | Chemotherapy | Doxorubicin hcl injection | $254.80 | |
| 6-Apr | C50.4 | J9070 | Pharmacy Administered | Chemotherapy | Cyclophosphamide 100 MG inj | $531.88 | |
| 6-Apr | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 6-Apr | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 6-Apr | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 8-Apr | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 18-Apr | C50.4 | 99211 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $19.71 | |
| 18-Apr | C50.4 | 78472 | Specialist | Radiology | Gated Heart Planar Single | $252.10 | |
| 18-Apr | C50.4 | 78800 | Specialist | Radiology | Tumor Imaging Limited Area | $187.21 | |
| 20-Apr | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 20-Apr | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion 1 Hr | $146.44 | |
| 20-Apr | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo IV Infusion Addl Hr | $31.26 | |
| 20-Apr | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | Hydration IV Infusion Init | $57.08 | |
| 20-Apr | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | Chemo IV Push Sngl Drug | $112.80 | |
| 20-Apr | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 20-Apr | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 20-Apr | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 20-Apr | C50.4 | J9265 | Pharmacy Administered | Chemotherapy | Paclitaxel injection | $66.00 | |
| 20-Apr | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 20-Apr | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 20-Apr | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 20-Apr | C50.4 | J2060 | Pharmacy Retail | Pharmacy | Lorazepam injection | $4.28 | |
| 20-Apr | C50.4 | J8540 | Pharmacy Retail | Pharmacy | Oral dexamethasone | $70.46 | |
| 20-Apr | C50.4 | 854875 | Pharmacy Retail | Pharmacy | Zolipdem tartrate 10 mg oral tablet [Ambien] | $44.50 | |
| 21-Apr | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $102.27 | |
| 22-Apr | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 25-Apr | C50.4 | 90801 | Specialist | Mental health | Psy DX Interview | $153.91 | |
| 25-Apr | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 2-May | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 4-May | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $102.27 | |
| 4-May | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo admin, IV infusion, up to 1 hour | $146.44 | |
| 4-May | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo admin, IV infusion, each additional hour | $31.26 | |
| 4-May | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | IV infusion hydration, up to 1 hour | $57.08 | |
| 4-May | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | IV push, 1 drug | $112.80 | |
| 4-May | C50.4 | 36415 | Specialist | Office visits & procedures | Blood draw | $3.00 | |
| 4-May | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 4-May | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 4-May | C50.4 | J9265 | Pharmacy Administered | Chemotherapy | Paclitaxel injection | $66.00 | |
| 4-May | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 4-May | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 4-May | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 6-May | C50.4 | 96372 | Specialist | Office visits & procedures | Subq or IM injection | $23.10 | |
| 6-May | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 6-May | C50.4 | 99211 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $19.71 | |
| 9-May | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 16-May | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 18-May | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 18-May | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo admin, IV infusion, up to 1 hour | $146.44 | |
| 18-May | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo admin, IV infusion, each additional hour | $31.26 | |
| 18-May | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | IV infusion hydration, up to 1 hour | $57.08 | |
| 18-May | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | IV push, 1 drug | $112.80 | |
| 18-May | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 18-May | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 18-May | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 18-May | C50.4 | J9265 | Pharmacy Administered | Chemotherapy | Paclitaxel injection | $66.00 | |
| 18-May | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 18-May | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 18-May | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 18-May | C50.4 | J2060 | Pharmacy Retail | Pharmacy | Lorazepam injection | $4.28 | |
| 18-May | C50.4 | J8540 | Pharmacy Retail | Pharmacy | Oral dexamethasone | $70.46 | |
| 18-May | C50.4 | 854875 | Pharmacy Retail | Pharmacy | Zolipdem tartrate 10 mg oral tablet [Ambien] | $44.50 | |
| 20-May | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 20-May | C50.4 | 99211 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $19.71 | |
| 20-May | C50.4 | 96372 | Specialist | Office visits & procedures | Subq or IM injection | $23.10 | |
| 23-May | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 25-May | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 30-May | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 1-Jun | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 1-Jun | C50.4 | 96413 | Pharmacy Administered | Chemotherapy | Chemo admin, IV infusion, up to 1 hour | $146.44 | |
| 1-Jun | C50.4 | 96415 | Pharmacy Administered | Chemotherapy | Chemo admin, IV infusion, each additional hour | $31.26 | |
| 1-Jun | C50.4 | 96360 | Pharmacy Administered | Chemotherapy | IV infusion hydration, up to 1 hour | $57.08 | |
| 1-Jun | C50.4 | 96409 | Pharmacy Administered | Chemotherapy | IV push, 1 drug | $112.80 | |
| 1-Jun | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 1-Jun | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 1-Jun | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 1-Jun | C50.4 | J9265 | Pharmacy Administered | Chemotherapy | Paclitaxel injection | $66.00 | |
| 1-Jun | C50.4 | J1644 | Pharmacy Administered | Chemotherapy | Inj heparin sodium per 1000u | $0.80 | |
| 1-Jun | C50.4 | J1100 | Pharmacy Administered | Chemotherapy | Dexamethasone sodium phos | $6.00 | |
| 1-Jun | C50.4 | J2405 | Pharmacy Administered | Chemotherapy | Ondansetron hcl injection | $13.10 | |
| 3-Jun | C50.4 | 96372 | Specialist | Office visits & procedures | Subq or IM injection | $23.10 | |
| 3-Jun | C50.4 | J2505 | Pharmacy Administered | Chemotherapy | Injection, pegfilgrastim 6mg | $2,576.49 | |
| 3-Jun | C50.4 | 99211 | Specialist | Office visits & procedures | Office/Outpatient Visit Est | $19.71 | |
| 6-Jun | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 13-Jun | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 20-Jun | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 20-Jun | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 27-Jun | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 29-Jun | C50.4 | 99205 | Specialist | Office visits & procedures | Office/Outpatient visit new | $171.73 | |
| 29-Jun | C50.4 | 77290 | Specialist | Radiation therapy | Set Radiation Therapy Field | $530.03 | |
| 29-Jun | C50.4 | 77333 | Specialist | Radiation therapy | Radiation Treatment Aid(s) | $59.80 | |
| 29-Jun | C50.4 | 77300 | Specialist | Radiation therapy | Radiation Therapy Dose Plan | $31.26 | |
| 29-Jun | C50.4 | 77263 | Specialist | Radiation therapy | Radiation Therapy Planning | $161.73 | |
| 29-Jun | C50.4 | 77331 | Specialist | Radiation therapy | Special Radiation Dosimetry | $43.83 | |
| 4-Jul | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 4-Jul | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 4-Jul | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 4-Jul | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 4-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 5-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 6-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 7-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 8-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 8-Jul | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 8-Jul | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 8-Jul | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 8-Jul | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 11-Jul | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 11-Jul | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 11-Jul | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 11-Jul | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 11-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 12-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 13-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 14-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 15-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 18-Jul | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 18-Jul | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 18-Jul | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 18-Jul | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 18-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 18-Jul | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 19-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 20-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 21-Jul | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 21-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 22-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 25-Jul | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 25-Jul | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 25-Jul | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 25-Jul | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 25-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 26-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 25-Jul | C50.4 | 77331 | Specialist | Radiation therapy | Special Radiation Dosimetry | $43.83 | |
| 25-Jul | C50.4 | 77300 | Specialist | Radiation therapy | Radiation Therapy Dose Plan | $31.26 | |
| 25-Jul | C50.4 | 77280 | Specialist | Radiation therapy | Set Radiation Therapy Field | $153.91 | |
| 25-Jul | C50.4 | 77263 | Specialist | Radiation therapy | Radiation Therapy Planning | $161.73 | |
| 27-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 28-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 29-Jul | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 1-Aug | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 1-Aug | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 1-Aug | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 1-Aug | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 1-Aug | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 2-Aug | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 3-Aug | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 4-Aug | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 5-Aug | C50.4 | 77413 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 8-Aug | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 8-Aug | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 8-Aug | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 8-Aug | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 8-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 9-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 10-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 11-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 11-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 15-Aug | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 15-Aug | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 15-Aug | C50.4 | 77427 | Specialist | Radiation therapy | Radiation TX Management X5 | $180.41 | |
| 15-Aug | C50.4 | 77417 | Specialist | Radiation therapy | Radiology port films | $14.95 | |
| 15-Aug | C50.4 | 77336 | Specialist | Radiation therapy | Radiation Physics Consult | $52.32 | |
| 15-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 16-Aug | C50.4 | 77414 | Specialist | Radiation therapy | Radiation Treatment Delivery | $234.44 | |
| 22-Aug | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 29-Aug | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 2-Sep | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 2-Sep | C50.4 | 85025 | Specialist | Laboratory tests | Complete CBC W/Auto Diff WBC | $10.94 | |
| 2-Sep | C50.4 | 80053 | Specialist | Laboratory tests | Comprehen metabolic panel | $14.87 | |
| 2-Sep | C50.4 | 36415 | Specialist | Office visits & procedures | Routine Venipuncture | $3.00 | |
| 5-Sep | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 12-Sep | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 12-Sep | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 16-Sep | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
| 19-Sep | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 26-Sep | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 3-Oct | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 10-Oct | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 10-Oct | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 17-Oct | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 24-Oct | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 31-Oct | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 7-Nov | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 7-Nov | C50.4 | 248642 | Pharmacy Retail | Pharmacy | Fluoxetine 20 mg oral tablet | $22.67 | |
| 14-Nov | C50.4 | 90806 | Specialist | Mental health | Psytx Off 45-50 Min | $89.91 | |
| 16-Nov | C50.4 | 99214 | Specialist | Office visits & procedures | Office/Outpatient visit est | $102.27 | |
Sheet 3: Provider Types
| Provider Type | |
| The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids the insurers in applying benefits to each service. | |
| Provider Type | What providers are covered under this Provider Type and other notes: |
| Primary | Primary Care Physician or non-Specialist |
| Specialist | Cardiology, Dermatology, Neurology, etc. |
| Alternative Provider | Chiropractor, Acupuncturist, etc. |
| Outpatient Facility | |
| Inpatient Facility | |
| Pharmacy Retail | |
| Pharmacy Mail Order | |
| Pharmacy Administered | All prescriptions reimburseable under a Pharmacy plan that are administered in a provider's office or hospital |
| Emergency Room | |
| Home Health | |
| Skilled Nursing Facility | |
| Ambulance | |
Sheet 4: Sample Care Cost Categories
| Sample Care Cost Categories | |
| The following are the sample care cost categories to use on the "Scenario" tab ~ "Category" column to classify each service so that they roll up to the same sample care cost categories in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" tab and Coverage Example label. | |
| Category | What services are covered under this Category and other notes: |
| Office visits & procedures | Includes services by all physicians (primary care, specialist, etc.) and alternative providers (chiropractor, acupuncture, etc.) |
| First office visit | Applies to maternity scenario only; other scenarios would use "Office visits & procedures" |
| Anesthesia | |
| Chemotherapy | |
| Circumcision | |
| Emergency care | Includes emergency room facility charges, physician services, ambulance transportation |
| Home health care | |
| Hospital charges | Facility charges for inpatient/outpatient services; discharge management |
| Hospital charges (baby) | Applies to maternity scenario only; other scenarios would use "Hospital charges" |
| Hospital charges (mother) | Applies to maternity scenario only; other scenarios would use "Hospital charges" |
| Inpatient medical care | Services by physicians, surgeons, anesthesiologists, etc. |
| Laboratory tests | Includes blood work |
| Medical equipment & supplies | Includes durable medical equipment, orthotics, prosthetics |
| Mental health | |
| Outpatient surgery | Physician and facility charges |
| Pharmacy | Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not administered in a hospital, physician's office or other facility |
| Radiation therapy | |
| Radiology | Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays |
| Rehabilitation services | Includes provision of treatment at any facility |
| Routine obstetric care | Applies to maternity scenario only; typically a bundled payment |
| Skilled nursing care | |
| Vaccines, other preventive | |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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