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Summary of Benefits and Coverage and Uniform Glossary
ICR 201108-0938-003 · OMB 0938-1146 · Object 27000301.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Summary of Benefits and Coverage and Uniform Glossary |
| Author | User |
| Last Modified By | Calc |
| File Modified | 2011-08-23 |
| File Created | 2026-09-15 |
| Conversion State | complete |
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Breast Cancer Clinical Benefit Scenario A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 B Treating breast cancer (lumpectomy, chemotherapy, radiation) Sample care costs: Office visits & procedures Radiology Laboratory tests Outpatient surgery Chemotherapy Radiation therapy Prostheses (wig) Pharmacy Mental health Total $2,800 $2,100 $1,500 $1,900 $27,000 $10,500 $300 $1,100 $2,800 $50,000 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] Page 1 of 14 Breast Cancer Clinical Benefit Scenario C 1 D 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. 2 3 Instructions for HHS: 4 * HHS to provide this label exactly as they want it to appear on the Summary of Coverage. 5 * HHS to reuse existing sample care cost categories unless a new category is required. 6 * HHS to specify no more than 11 sample care cost categories as space on the page with 12 point font dictates. 7 * All of these costs roll up from the Scenario tab; HHS to confirm these totals match to the Scenario tab. 8 9 10 11 12 13 * This total must match the total on the Scenario tab; HHS to confirm it matches before issuing to insurers. 14 15 16 the scenario. o calculate 17 18 19 assumptions regardless of scenario.) pply these 20 21 d under22the plan. 23 in Sample Care Costs. variation 24 25 26 greater27than $100 are rounded to the nearest hundredth. 28 $100 are rounded to the nearest tenth. less than 29 30 the lowest level of cost sharing), for those products that incorporate tiered provider networks. ciated with 31 32 ecify special assumptions.) 33 Page 2 of 14 E Breast Cancer Clinical Benefit Scenario 1 A Medical Condition: B C D E F G 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 2 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. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Date of Service Total 3-Jan 3-Jan 7-Jan 7-Jan 8-Jan 10-Jan 10-Jan 10-Jan 10-Jan 14-Jan 14-Jan 14-Jan 14-Jan 21-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount 50186.72 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 99214 77057 99205 77055 77059 99214 85025 80053 36415 99214 19102 76942 88307 99214 00404 77057 19290 38792 J2250 J3010 78195 38525 19302 88305 88307 76098 Primary Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Office visits & procedures Radiology Office visits & procedures Radiology Radiology Office visits & procedures Laboratory tests Laboratory tests Office visits & procedures Office visits & procedures Office visits & procedures Radiology Laboratory tests Office visits & procedures Anesthesia Radiology Outpatient surgery Outpatient surgery Outpatient surgery Outpatient surgery Outpatient surgery Outpatient surgery Outpatient surgery Laboratory tests Laboratory tests Radiology Page 3 of 14 Office/Outpatient visit est Mammogram Screening Office/Outpatient Visit New Mammogram One Breast MRI Both Breasts Office/Outpatient visit est Complete CBC W/Auto Diff WBC Comprehen Metabolic Panel Routine Venipuncture Office/Outpatient visit est BX Breast Percut W/Image Echo Guide For Biopsy Tissue Exam By Pathologist Office/Outpatient visit est Anest Surgery of Breast Mammogram Screening Place needle wire breast Identify Sentinel Node Inj midazolam hydrochloride Fentanyl citrate injection Lymph System Imaging Biopsy/Removal Lymph Nodes P-Mastectomy W/LN Removal Tissue Exam By Pathologist Tissue Exam By Pathologist X-Ray Exam Breast Specimen $102.27 $81.20 $171.73 $86.64 $787.23 $102.27 $10.94 $14.87 $3.00 $102.27 $212.69 $198.08 $226.28 $102.27 $395.21 $81.20 $159.35 $40.43 $1.73 $18.53 $352.68 $424.03 $867.42 $106.01 $226.28 $19.37 A 3 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 Date of Service B C D E F G Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount Laboratory tests Laboratory tests Laboratory tests Laboratory tests Laboratory tests Laboratory tests In Situ Hybridization (FISH) Path Consult Intraop 1 Bloc Cyto/Molecular Report Tumor Immunohistochem/Comput Assay Of Estrogen Assay Of Progesterone Acetaminophen 500 mg / Hydrocodone bitartrate 7.5 mg, oral tablet Office/Outpatient Visit Est Gated Heart Planar Single Tumor Imaging Limited Area Wig any type Office/Outpatient visit est Chemo IV Infusion 1 Hr Chemo IV Infusion Addl Hr Chemo IV Push Sngl Drug Hydration IV Infusion Init Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen Metabolic Panel Doxorubicin hcl injection Cyclophosphamide 100 MG inj Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Lorazepam injection Ondansetron hcl injection Zolipdem tartrate 10 mg oral tablet [Ambien] Injection, pegfilgrastim 6mg Office/Outpatient visit est Office/Outpatient visit est Chemo IV Infusion 1 Hr Chemo IV Infusion Addl Hr Chemo IV Push Sngl Drug Hydration IV Infusion Init Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen Metabolic Panel Doxorubicin hcl injection Cyclophosphamide 100 MG inj Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Injection, pegfilgrastim 6mg Office/Outpatient visit est Chemo IV Infusion 1 Hr 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan 31-Jan C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 88365 88331 88291 88361 84233 84234 Specialist Specialist Specialist Specialist Specialist Specialist 31-Jan 21-Feb 21-Feb 21-Feb 21-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 23-Feb 25-Feb 1-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 9-Mar 11-Mar 23-Mar 23-Mar C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 857118 99215 78472 78800 A9282 99214 96413 96415 96409 96360 36415 85025 80053 J9000 J9070 J1644 J1100 J2405 J2060 J2405 854875 J2505 99214 99214 96413 96415 96409 96360 36415 85025 80053 J9000 J9070 J1644 J1100 J2405 J2505 99214 96413 Pharmacy Retail Specialist Specialist Specialist Alternative Provider Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Retail Pharmacy Retail Pharmacy Retail Pharmacy Administered Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Pharmacy Administered Pharmacy Office visits & procedures Radiology Radiology Prostheses (wig) Office visits & procedures Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Pharmacy Pharmacy Pharmacy Chemotherapy Office visits & procedures Office visits & procedures Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Chemotherapy $165.47 $91.40 $29.29 $151.53 $90.64 $91.29 $16.04 $137.60 $252.10 $187.21 $265.00 $102.27 $146.44 $31.26 $112.80 $57.08 $3.00 $10.94 $14.87 $254.78 $531.88 $0.80 $6.00 $13.10 $4.28 $269.73 $44.50 $2,576.49 $102.27 $102.27 $146.44 $31.26 $112.80 $57.08 $3.00 $10.94 $14.87 $254.80 $531.88 $0.80 $6.00 $13.10 $2,576.49 $102.27 $146.44 Breast Cancer Clinical Benefit Scenario A 3 Date of Service 76 23-Mar 77 23-Mar 78 23-Mar 79 23-Mar 80 23-Mar 81 23-Mar 82 23-Mar 83 23-Mar 84 23-Mar 85 23-Mar 86 23-Mar 87 23-Mar 88 23-Mar 89 25-Mar 90 25-Mar 91 6-Apr 92 6-Apr 93 6-Apr 94 6-Apr 95 6-Apr 96 6-Apr 97 6-Apr 98 6-Apr 99 6-Apr 100 6-Apr 101 6-Apr 102 6-Apr 103 6-Apr 104 8-Apr 105 18-Apr 106 18-Apr 107 18-Apr 108 20-Apr 109 20-Apr 110 20-Apr 111 20-Apr 112 20-Apr 113 20-Apr 114 20-Apr 115 20-Apr 116 20-Apr 117 20-Apr 118 20-Apr 119 20-Apr 120 20-Apr 121 20-Apr B C D E F G Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Retail Pharmacy Retail Pharmacy Retail Pharmacy Administered Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Retail Pharmacy Retail Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Pharmacy Pharmacy Pharmacy Chemotherapy Office visits & procedures Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Radiology Radiology Office visits & procedures Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Pharmacy Pharmacy C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 96415 96409 96360 36415 85025 80053 J9000 J9070 J1644 J1100 J2405 J2060 J2405 854875 J2505 99214 96413 96415 96409 96360 36415 85025 80053 J9000 J9070 J1644 J1100 J2405 J2505 99211 78472 78800 99214 96413 96415 96360 96409 36415 85025 80053 J9265 J1644 J1100 J2405 J2060 J8540 Page 5 of 14 Chemo IV Infusion Addl Hr Chemo IV Push Sngl Drug Hydration IV Infusion Init Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen Metabolic Panel Doxorubicin hcl injection Cyclophosphamide 100 MG inj Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Lorazepam injection Ondansetron hcl injection Zolipdem tartrate 10 mg oral tablet [Ambien] Injection, pegfilgrastim 6mg Office/Outpatient visit est Chemo IV Infusion 1 Hr Chemo IV Infusion Addl Hr Chemo IV Push Sngl Drug Hydration IV Infusion Init Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen metabolic panel Doxorubicin hcl injection Cyclophosphamide 100 MG inj Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Injection, pegfilgrastim 6mg Office/Outpatient Visit Est Gated Heart Planar Single Tumor Imaging Limited Area Office/Outpatient visit est Chemo IV Infusion 1 Hr Chemo IV Infusion Addl Hr Hydration IV Infusion Init Chemo IV Push Sngl Drug Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen metabolic panel Paclitaxel injection Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Lorazepam injection Oral dexamethasone $31.26 $112.80 $57.08 $3.00 $10.94 $14.87 $254.80 $531.88 $0.80 $6.00 $13.10 $4.28 $269.73 $44.50 $2,576.49 $102.27 $146.44 $31.26 $112.80 $57.08 $3.00 $10.94 $14.87 $254.80 $531.88 $0.80 $6.00 $13.10 $2,576.49 $19.71 $252.10 $187.21 $102.27 $146.44 $31.26 $57.08 $112.80 $3.00 $10.94 $14.87 $66.00 $0.80 $6.00 $13.10 $4.28 $70.46 A 3 Date of Service 122 20-Apr 123 21-Apr 124 22-Apr 125 25-Apr 126 25-Apr 127 2-May 128 4-May 129 4-May 130 4-May 131 4-May 132 4-May 133 4-May 134 4-May 135 4-May 136 4-May 137 4-May 138 4-May 139 4-May 140 6-May 141 6-May 142 6-May 143 9-May 144 16-May 145 18-May 146 18-May 147 18-May 148 18-May 149 18-May 150 18-May 151 18-May 152 18-May 153 18-May 154 18-May 155 18-May 156 18-May 157 18-May 158 18-May 159 18-May 160 20-May 161 20-May 162 20-May 163 23-May 164 25-May 165 30-May 166 1-Jun 167 1-Jun B C D E F G Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount Pharmacy Retail Specialist Pharmacy Administered Specialist Pharmacy Retail Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Pharmacy Administered Specialist Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Retail Pharmacy Retail Pharmacy Retail Pharmacy Administered Specialist Specialist Specialist Pharmacy Retail Specialist Specialist Pharmacy Administered Pharmacy Office visits & procedures Chemotherapy Mental health Pharmacy Mental health Office visits & procedures Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Chemotherapy Office visits & procedures Mental health Mental health Office visits & procedures Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Pharmacy Pharmacy Pharmacy Chemotherapy Office visits & procedures Office visits & procedures Mental health Pharmacy Mental health Office visits & procedures Chemotherapy C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 854875 99214 J2505 90801 248642 90806 99214 96413 96415 96360 96409 36415 85025 80053 J9265 J1644 J1100 J2405 96372 J2505 99211 90806 90806 99214 96413 96415 96360 96409 36415 85025 80053 J9265 J1644 J1100 J2405 J2060 J8540 854875 J2505 99211 96372 90806 248642 90806 99214 96413 Zolipdem tartrate 10 mg oral tablet [Ambien] Office/Outpatient Visit Est Injection, pegfilgrastim 6mg Psy DX Interview Fluoxetine 20 mg oral tablet Psytx Off 45-50 Min Office/Outpatient Visit Est Chemo admin, IV infusion, up to 1 hour Chemo admin, IV infusion, each additional hour IV infusion hydration, up to 1 hour IV push, 1 drug Blood draw Complete CBC W/Auto Diff WBC Comprehen metabolic panel Paclitaxel injection Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Subq or IM injection Injection, pegfilgrastim 6mg Office/Outpatient Visit Est Psytx Off 45-50 Min Psytx Off 45-50 Min Office/Outpatient visit est Chemo admin, IV infusion, up to 1 hour Chemo admin, IV infusion, each additional hour IV infusion hydration, up to 1 hour IV push, 1 drug Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen metabolic panel Paclitaxel injection Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Lorazepam injection Oral dexamethasone Zolipdem tartrate 10 mg oral tablet [Ambien] Injection, pegfilgrastim 6mg Office/Outpatient Visit Est Subq or IM injection Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Psytx Off 45-50 Min Office/Outpatient visit est Chemo admin, IV infusion, up to 1 hour $44.50 $102.27 $2,576.49 $153.91 $22.67 $89.91 $102.27 $146.44 $31.26 $57.08 $112.80 $3.00 $10.94 $14.87 $66.00 $0.80 $6.00 $13.10 $23.10 $2,576.49 $19.71 $89.91 $89.91 $102.27 $146.44 $31.26 $57.08 $112.80 $3.00 $10.94 $14.87 $66.00 $0.80 $6.00 $13.10 $4.28 $70.46 $44.50 $2,576.49 $19.71 $23.10 $89.91 $22.67 $89.91 $102.27 $146.44 Breast Cancer Clinical Benefit Scenario A 3 Date of Service 168 1-Jun 169 1-Jun 170 1-Jun 171 1-Jun 172 1-Jun 173 1-Jun 174 1-Jun 175 1-Jun 176 1-Jun 177 1-Jun 178 3-Jun 179 3-Jun 180 3-Jun 181 6-Jun 182 13-Jun 183 20-Jun 184 20-Jun 185 27-Jun 186 29-Jun 187 29-Jun 188 29-Jun 189 29-Jun 190 29-Jun 191 29-Jun 192 4-Jul 193 4-Jul 194 4-Jul 195 4-Jul 196 4-Jul 197 5-Jul 198 6-Jul 199 7-Jul 200 8-Jul 201 8-Jul 202 8-Jul 203 8-Jul 204 8-Jul 205 11-Jul 206 11-Jul 207 11-Jul 208 11-Jul 209 11-Jul 210 12-Jul 211 13-Jul 212 14-Jul 213 15-Jul B C D E F G Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Specialist Specialist Pharmacy Administered Pharmacy Administered Pharmacy Administered Pharmacy Administered Specialist Pharmacy Administered Specialist Specialist Specialist Specialist Pharmacy Retail Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Laboratory tests Laboratory tests Chemotherapy Chemotherapy Chemotherapy Chemotherapy Office visits & procedures Chemotherapy Office visits & procedures Mental health Mental health Mental health Pharmacy Mental health Office visits & procedures Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Mental health Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Laboratory tests Laboratory tests Office visits & procedures Office visits & procedures Mental health Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 96415 96360 96409 36415 85025 80053 J9265 J1644 J1100 J2405 96372 J2505 99211 90806 90806 90806 248642 90806 99205 77290 77333 77300 77263 77331 90806 77336 77417 77427 77413 77413 77413 77413 77413 80053 85025 36415 99214 90806 77336 77417 77427 77413 77413 77413 77413 77413 Page 7 of 14 Chemo admin, IV infusion, each additional hour IV infusion hydration, up to 1 hour IV push, 1 drug Routine Venipuncture Complete CBC W/Auto Diff WBC Comprehen metabolic panel Paclitaxel injection Inj heparin sodium per 1000u Dexamethasone sodium phos Ondansetron hcl injection Subq or IM injection Injection, pegfilgrastim 6mg Office/Outpatient Visit Est Psytx Off 45-50 Min Psytx Off 45-50 Min Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Psytx Off 45-50 Min Office/Outpatient visit new Set Radiation Therapy Field Radiation Treatment Aid(s) Radiation Therapy Dose Plan Radiation Therapy Planning Special Radiation Dosimetry Psytx Off 45-50 Min Radiation Physics Consult Radiology port films Radiation TX Management X5 Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Comprehen metabolic panel Complete CBC W/Auto Diff WBC Routine Venipuncture Office/Outpatient visit est Psytx Off 45-50 Min Radiation Physics Consult Radiology port films Radiation TX Management X5 Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery $31.26 $57.08 $112.80 $3.00 $10.94 $14.87 $66.00 $0.80 $6.00 $13.10 $23.10 $2,576.49 $19.71 $89.91 $89.91 $89.91 $22.67 $89.91 $171.73 $530.03 $59.80 $31.26 $161.73 $43.83 $89.91 $52.32 $14.95 $180.41 $234.44 $234.44 $234.44 $234.44 $234.44 $14.87 $10.94 $3.00 $102.27 $89.91 $52.32 $14.95 $180.41 $234.44 $234.44 $234.44 $234.44 $234.44 A 3 Date of Service 214 18-Jul 215 18-Jul 216 18-Jul 217 18-Jul 218 18-Jul 219 18-Jul 220 19-Jul 221 20-Jul 222 21-Jul 223 21-Jul 224 22-Jul 225 25-Jul 226 25-Jul 227 25-Jul 228 25-Jul 229 25-Jul 230 26-Jul 231 25-Jul 232 25-Jul 233 25-Jul 234 25-Jul 235 27-Jul 236 28-Jul 237 29-Jul 238 1-Aug 239 1-Aug 240 1-Aug 241 1-Aug 242 1-Aug 243 2-Aug 244 3-Aug 245 4-Aug 246 5-Aug 247 8-Aug 248 8-Aug 249 8-Aug 250 8-Aug 251 8-Aug 252 9-Aug 253 10-Aug 254 11-Aug 255 11-Aug 256 15-Aug 257 15-Aug 258 15-Aug 259 15-Aug B C D E F G Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 90806 248642 77427 77417 77413 77336 77413 77413 99214 77413 77413 90806 77336 77427 77417 77413 77413 77331 77300 77280 77263 77413 77413 77413 90806 77427 77417 77336 77413 77413 77413 77413 77413 90806 77427 77417 77336 77414 77414 77414 77414 77414 90806 248642 77427 77417 Specialist Pharmacy Retail Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Pharmacy Retail Specialist Specialist Mental health Pharmacy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Office visits & procedures Radiation therapy Radiation therapy Mental health Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Mental health Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Mental health Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Mental health Pharmacy Radiation therapy Radiation therapy Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Radiation TX Management X5 Radiology port films Radiation Treatment Delivery Radiation Physics Consult Radiation Treatment Delivery Radiation Treatment Delivery Office/Outpatient visit est Radiation Treatment Delivery Radiation Treatment Delivery Psytx Off 45-50 Min Radiation Physics Consult Radiation TX Management X5 Radiology port films Radiation Treatment Delivery Radiation Treatment Delivery Special Radiation Dosimetry Radiation Therapy Dose Plan Set Radiation Therapy Field Radiation Therapy Planning Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Psytx Off 45-50 Min Radiation TX Management X5 Radiology port films Radiation Physics Consult Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Psytx Off 45-50 Min Radiation TX Management X5 Radiology port films Radiation Physics Consult Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Radiation Treatment Delivery Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Radiation TX Management X5 Radiology port films $89.91 $22.67 $180.41 $14.95 $234.44 $52.32 $234.44 $234.44 $102.27 $234.44 $234.44 $89.91 $52.32 $180.41 $14.95 $234.44 $234.44 $43.83 $31.26 $153.91 $161.73 $234.44 $234.44 $234.44 $89.91 $180.41 $14.95 $52.32 $234.44 $234.44 $234.44 $234.44 $234.44 $89.91 $180.41 $14.95 $52.32 $234.44 $234.44 $234.44 $234.44 $234.44 $89.91 $22.67 $180.41 $14.95 Breast Cancer Clinical Benefit Scenario A 3 Date of Service 260 15-Aug 261 15-Aug 262 16-Aug 263 22-Aug 264 29-Aug 265 2-Sep 266 2-Sep 267 2-Sep 268 2-Sep 269 5-Sep 270 12-Sep 271 12-Sep 272 16-Sep 273 19-Sep 274 26-Sep 275 3-Oct 276 10-Oct 277 10-Oct 278 17-Oct 279 24-Oct 280 31-Oct 281 7-Nov 282 7-Nov 283 14-Nov 284 16-Nov B C D E F G Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Notes Allowed Amount C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 C50.4 77336 77414 77414 90806 90806 99214 85025 80053 36415 90806 90806 248642 99214 90806 90806 90806 90806 248642 90806 90806 90806 90806 248642 90806 99214 Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Specialist Pharmacy Retail Specialist Specialist Specialist Specialist Specialist Pharmacy Retail Specialist Specialist Specialist Specialist Pharmacy Retail Specialist Specialist Radiation therapy Radiation therapy Radiation therapy Mental health Mental health Office visits & procedures Laboratory tests Laboratory tests Office visits & procedures Mental health Mental health Pharmacy Office visits & procedures Mental health Mental health Mental health Mental health Pharmacy Mental health Mental health Mental health Mental health Pharmacy Mental health Office visits & procedures Page 9 of 14 Radiation Physics Consult Radiation Treatment Delivery Radiation Treatment Delivery Psytx Off 45-50 Min Psytx Off 45-50 Min Office/Outpatient visit est Complete CBC W/Auto Diff WBC Comprehen metabolic panel Routine Venipuncture Psytx Off 45-50 Min Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Office/Outpatient visit est Psytx Off 45-50 Min Psytx Off 45-50 Min Psytx Off 45-50 Min Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Psytx Off 45-50 Min Psytx Off 45-50 Min Psytx Off 45-50 Min Psytx Off 45-50 Min Fluoxetine 20 mg oral tablet Psytx Off 45-50 Min Office/Outpatient visit est $52.32 $234.44 $234.44 $89.91 $89.91 $102.27 $10.94 $14.87 $3.00 $89.91 $89.91 $22.67 $102.27 $89.91 $89.91 $89.91 $89.91 $22.67 $89.91 $89.91 $89.91 $89.91 $22.67 $89.91 $102.27 H 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Breast Cancer Clinical Benefit Scenario A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 B 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 Primary Specialist Alternative Provider Outpatient Facility Inpatient Facility Pharmacy Retail Pharmacy Mail Order Pharmacy Administered Emergency Room Home Health Skilled Nursing Facility Ambulance What providers are covered under this Provider Type and other notes: Primary Care Physician or non-Specialist Cardiology, Dermatology, Neurology, etc. Chiropractor, Acupuncturist, etc. All prescriptions reimburseable under a Pharmacy plan that are administered in a provider's office or hospital Page 11 of 14 Sample Care Cost Categories The following are the sample care cost categories to use on the "Scenario" tab ~ "Category" column to classify each sample care cost categories in the Coverage Example label on the "Label and Assumptions" tab. This facilitates con Coverage Example label. Category Office visits & procedures First office visit Anesthesia Chemotherapy Circumcision Emergency care Home health care Hospital charges Hospital charges (baby) Hospital charges (mother) Inpatient medical care Laboratory tests Medical equipment & supplies Mental health Outpatient surgery Pharmacy Radiation therapy Radiology Rehabilitation services Routine obstetric care Skilled nursing care Vaccines, other preventive mple care cost categories to use on the "Scenario" tab ~ "Category" column to classify each service so that they roll up to the s ories in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" ta l. What services are covered under this Category and other notes: Includes services by all physicians (primary care, specialist, etc.) and alternative providers (chiropractor, acupunctur Applies to maternity scenario only; other scenarios would use "Office visits & procedures" Includes emergency room facility charges, physician services, ambulance transportation Facility charges for inpatient/outpatient services; discharge management Applies to maternity scenario only; other scenarios would use "Hospital charges" Applies to maternity scenario only; other scenarios would use "Hospital charges" Services by physicians, surgeons, anesthesiologists, etc. Includes blood work Includes durable medical equipment, orthotics, prosthetics Physician and facility charges Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not administered in a hospital, ph Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays Includes provision of treatment at any facility Applies to maternity scenario only; typically a bundled payment ysician's office or other facility