CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In

2022 Part D EOB Exhibit G

EXHIBIT G.
Example of a Part D EOB (all sections included)
The fictional example in this exhibit is designed to illustrate the
full document. It includes all sections for the model Part D
Explanation of Benefits (EOB).
It is for a person enrolled in an MA-PD in the Initial Coverage
payment stage who does not have LIS or Supplemental Drug
Coverage but does have additional gap coverage. It shows what
the EOB might look like for a member who has only a couple of
prescriptions filled during the month and does not have any
updates to the formulary.

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Your Monthly Prescription Drug Summary
For September, 2022
October 8, 2022
To:
{insert member name}
{insert member street address}
{insert member city, state zip code}
{insert member ID numbers and/or other
reference}

For languages other than
English:
Español 1-800-331-2345 (Spanish)
Русский 1-800-331-5678 (Russian)
tiếng Việt 1-800-331-7777 (Vietnamese)

Do you need large print or
another format?
To get this material in other formats,
including large type, Braille, and translation
into other languages, call Birchwood
Member Services at the number shown on
this page.
Birchwood Health Corporation
{insert full mailing address}
CMS-10141

This summary is your “Explanation of Benefits” (EOB) for your Medicare
prescription drug coverage (Part D). Please review this summary and keep it for
your records. (This is not a bill.)
Here are the sections in this summary:
SECTION 1. Your prescriptions during the past month
SECTION 2. Which “drug payment stage” are you in?
SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and definitions)
SECTION 4. Updates to the plan’s Drug List that affect drugs you take
SECTION 5. If you see mistakes on this summary or have questions, what should you
do?
SECTION 6. Important things to know about your drug coverage and your rights

Birchwood Member Services
If you have questions or need help, call us. We are available Monday through Friday
from 8 am to 5 pm. Calls to these numbers are free.
1-800-222-3333
1-888-444-5555 for TTY / TDD only
1-800-111-7788 fax
Or visit our website: http://www.birchwood.com
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SECTION 1. Your prescriptions during the past month
•

Chart 1 shows your prescriptions for covered Part D drugs for the past month.

•

Please look over this information about your prescriptions to be sure that it is correct. If
you have any questions or think there is a mistake, Section 5 tells what you should do.

•

Drug Pricing Information (Drug Price & Price Change)
o The Drug Price shows the cost of each drug (including what you, your plan and other programs paid). The Price Change
shows the percentage change of the drug price from when your prescription was first filled during the current benefit year.
o There may be Lower Cost Therapeutic Alternative drugs (when applicable) listed below some of your current drugs. These
are drugs that may be an alternative to the ones you are taking but with lower cost-sharing or a lower drug price. You may want
to speak with your prescriber to see if the lower cost therapeutic alternative is right for you.

CHART 1.

Your prescriptions for covered Part D drugs
September 2022
{insert name of first drug} 30 mg tabs
09/10/22, ABC Pharmacy
Rx# 22200374, 30 days supply

Plan paid

$48.29

You paid

Other payments

(made by programs or
organizations; see
Section 3)

$16.21

$0.00

$22.60

$0.00

Lower Cost Therapeutic Alternatives: {insert
options, if applicable}
{insert name of second drug} 50 mg caps
09/21/22, ABC Pharmacy
Rx# 67114291, 30 days supply
Lower Cost Therapeutic Alternatives: {insert
options, if applicable}

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$72.34

Drug Price
& Price
Change

$64.50
-3.5%

$94.94
+5%

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CHART 1.
Your prescriptions for covered Part D drugs
September 2022
TOTALS for the month of September 2022:
Your “out-of-pocket costs” amount is $38.81. (This is
the amount you paid this month ($38.81) plus the
amount of “other payments” made this month that count
toward your “out-of-pocket costs” ($0.00). See
definitions in Section 3.)

4

Plan paid

$120.63
(total for the
month)

You paid

$38.81
(total for the
month)

Other payments

(made by programs or
organizations; see
Section 3)

Drug Price
& Price
Change

$0.00
(total for the month)

Your “total drug costs” amount is $159.44. (This is
the total of all payments made for your drugs this month
by the plan ($120.63) and you ($38.81) plus “other
payments” ($0.00).)

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Plan paid

You paid

$329.43

$445.00

(year-to-date total)

(year-to-date total)

Year-to-date totals as of 9/30/2022
Your year-to-date amount for “out-of-pocket costs”
is $445.00.

Other payments

(made by programs or
organizations; see
Section 3)
$0.00
(year-to-date total)

Your year-to-date amount for “total drug costs” is
$774.43.
For more about “out-of-pocket costs” and “total drug costs,”
see Section 3.

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SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible

STAGE 2
Initial Coverage

STAGE 3
Coverage Gap

STAGE 4
Catastrophic Coverage

• You began in this payment
stage when you filled your
first prescription of the year.
During this stage, you (or
others on your behalf) paid
the full cost of your drugs.

• Now that you are in this payment
stage, the plan pays its share of the
cost of your drugs and you (or others
on your behalf) pay your share of the
cost.

• During this payment stage,
you (or others on your
behalf) receive a 70%
manufacturer’s discount on
covered brand name drugs
and the plan will cover at
least another 5%, so you
will pay less than 25% of
the negotiated price on
brand-name drugs. In
addition you (or others on
your behalf) pay less than
25% of the costs of generic
drugs.

• Once you are in this
payment stage, the plan
will pay most of the
cost for your covered
drugs.

• You stayed in this stage
until you (or others on your
behalf) had paid $480 for
your drugs ($480 is the
amount of your deductible).
Then you moved to payment
stage 2, Initial Coverage.

• You will stay in this payment stage
until the amount of your year-todate “total drug costs” reaches
$4,430. As of 9/30/22, your year-todate “total drug costs” was $764.43.
(See definitions in Section 3.)

• Once you are in this
payment stage, you will
stay in it for the rest of
the calendar year
(through December 31,
2022).

• You generally stay in this
stage until the amount of
your year-to-date “out-ofpocket costs” (see Section
3) reaches $7,050. When
this happens, you move to
payment stage 4,
Catastrophic Coverage.

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What happens next?
Once you have an additional
$3,665.57 in “total drug costs,” you
will move to the next payment stage
(stage 3, Coverage Gap).

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SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and definitions)
We’re including this Section to help you keep track of your “out-of-pocket costs” and “total drug
costs” because these costs determine which drug payment stage you are in. And, as explained in
Section 2, the payment stage you are in determines how much you pay for your prescriptions.

Your “out-of-pocket costs”
$38.81

month of September 2022

$445.00 year-to-date (since January 2022)

Your “total drug costs”
$159.44 month of September 2022
$764.43 year-to-date (since January 2022)

DEFINITION:

DEFINITION:

“Out of pocket costs” includes:

“Total drug costs” is the total of all
payments made for your covered Part D
drugs. It includes:

•

What you pay when you fill or refill a prescription for a covered Part
D drug. (This includes payments for your drugs, if any, that are made
by family or friends.)

Payments made for your drugs by any of the following programs or
organizations: “Extra Help” from Medicare; Medicare’s Coverage Gap
Discount Program; Indian Health Service; AIDS drug assistance programs;
most charities; and most State Pharmaceutical Assistance Programs (SPAPs).

•

What the plan pays.

•

What you pay.

•

What others (programs or organizations)
pay for your drugs. (All of these payments
are included in your “total drug costs.”)

It does not include:
•

Payments made for: a) plan premiums, b) drugs not covered by our
plan, c) non-Part D drugs (such as drugs you receive during a hospital
stay), d) drugs obtained at a non-network pharmacy that does not
meet our out-of-network pharmacy access policy.

•

Payments made for your drugs by any of the following programs or
organizations: employer or union health plans, some governmentfunded programs (including TRICARE and the Veteran’s
Administration), Worker’s Compensation, and some other programs.

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Learn more. Medicare has made the rules about which types of payments count and do not count
toward “out-of-pocket costs” and “total drug costs.” The definitions on this page give you only
the main rules. For details, including more about “covered Part D drugs,” see the Evidence of
Coverage, our benefits booklet (for more about the Evidence of Coverage, see Section 6).

SECTION 4. Updates to the plan’s Drug List
that affect drugs you take
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At this time, there are no new or upcoming changes to our Drug
List that affect the coverage or cost of drugs you take. (By “drugs
you take,” we mean any plan-covered drugs for which you filled
prescriptions in 2022 as a member of our plan.)

SECTION 5. If you see mistakes on this
summary or have questions,
what should you do?
If you have questions, call us
If something is confusing or doesn’t look right on this
monthly prescription drug summary, please call us at
Birchwood Member Services (phone numbers are on the cover
of this summary). You can also find answers to many
questions at our website: http://www.birchwood.com.
What about possible fraud?
Most health care professionals and organizations that provide
Medicare services are honest. Unfortunately, there may be
some who are dishonest.
If this monthly summary shows drugs that you’re not taking,
or anything else that looks suspicious to you, please tell us so
that we can check into it.
• Call us at Birchwood Member Services (phone numbers are
on the cover of this summary).
• Or, call Medicare at 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048. You can call these
numbers for free, 24 hours a day, 7 days a week.

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SECTION 6. Important things to know
about your drug coverage and
your rights
Your “Evidence of Coverage” has the details about your drug
coverage and costs.
The Evidence of Coverage is our plan’s benefits booklet. It
explains your drug coverage and the rules you need to follow
when you are using your drug coverage.
We have sent you a copy of the Evidence of Coverage. If you need
another copy, please call us (phone numbers are on the cover of
this summary). This document is also available on our website:
http://www.birchwood.com. You may also elect to receive the
Evidence of Coverage electronically, please contact us if you
would like to change your method of delivery. If you need another
copy of either of these, please call us (phone numbers for
Birchwood Member Services are on the cover of this summary).
What if you have problems related to coverage
or payments for your drugs?
Your Evidence of Coverage has step-by-step instructions that
explain what to do if you have problems related to your drug
coverage and costs. Here are the chapters to look for:
• Chapter 7. Asking the plan to pay its share of a bill you
have received for covered services or drugs
• Chapter 9. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
Here are things to keep in mind:
• When we decide whether a drug is covered for you and
how much you must pay, it’s called a “coverage decision.”
If you disagree with our coverage decision, you can appeal
our decision (see Chapter 9 of the Evidence of Coverage).
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• Medicare has set the rules for how coverage
decisions and appeals are handled. These are legal
procedures and the deadlines are important. The
process can be done if your doctor tells us that
your health requires a quick decision.
Please ask for help if you need it. Here’s how:

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Assistance Programs (SPAPs) that help some people pay
for prescription drugs based on financial need, age, or
medical condition. Each state has different rules. Check
with your State Health Insurance Assistance Program
(SHIP). The name and phone numbers for this organization
are in Chapter 2, Section 3 of your Evidence of Coverage.

• You can call us at Birchwood Member Services (phone
numbers are on the cover of this monthly summary).
• You can call Medicare at 1-800-MEDICARE (1-800-6334227). TTY users should call 1-877-486-2048. You can
call these numbers for free, 24 hours a day, 7 days a week.
• You can call your State Health Insurance Assistance
Program (SHIP). The name and phone numbers for this
organization are in Chapter 2, Section 3 of your Evidence
of Coverage.
Did you know there are programs to help
people pay for their drugs?
•

“Extra Help” from Medicare. You may be able to get
Extra Help to pay for your prescription drug premiums and
costs. This program is also called the “low-income
subsidy” or LIS. People whose yearly income and
resources are below certain limits can qualify for this help.
To see if you qualify for getting Extra Help, see Section 7
of your Medicare & You 2022 handbook or call 1-800MEDICARE (1-800-633-4227). TTY users should call 1877-486-2048. You can call these numbers for free, 24
hours a day, 7 days a week. You can also call the Social
Security Office at 1-800-772-1213 between 7 a.m. and 7
p.m., Monday through Friday. TTY users should call 1800-325-0778. You can also call your State Medicaid
Office.

• Help from your state’s pharmaceutical assistance
program. Many states have State Pharmaceutical
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