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PO Box 789
Anytown, USA 12345-6789
THIS IS NOT A BILL
JENNIFER WASHINGTON
123 EXAMPLE STREET
APARTMENT A
ANYTOWN, USA 12345-6789
Notice for Jennifer Washington
Your Medicare Number
2CG5BJ6KS70
Date of This Notice
April 15, 2022
Claims Processed
Between
March 15 –
April 15, 2022
Your Medicare Part D Explanation of Benefits (EOB)
This is your “Explanation of Benefits” (EOB) for your Medicare prescription drug coverage (Part D). Your EOB
shows the prescriptions you filled, what we paid, what you and others have paid, and what counts towards your
out-of-pocket costs and your total drug costs.
• Your EOB is not a bill.
If you paid a co-pay or coinsurance for your drug, the EOB should show the amount you paid.
• You may not get an EOB every month.
When we get a claim (bill) from your pharmacy, you’ll get an EOB the next month. For example, if
we get a claim in March, you’ll get an EOB in April.
• Take a minute to look over your EOB.
Check your EOB to make sure everything is correct. If you have questions, find mistakes, or
suspect fraud, we’re happy to help. Call us at the number below.
BIRCHWOOD MEMBER SERVICES
If you have questions or need help, call us toll-free
Monday through Friday from 8 a.m. to 5 p.m.
1-800-222-3333
1-888-444-5555 for TTY/TDD only
1-800-111-7788 fax
Or visit our website:
www.birchwood.com
For languages other than English:
Español 1-800-331-2345 (Spanish)
Русский 1-800-331-5678 (Russian)
tieng Viet 1-800-331-7777 (Vietnamese)
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.
THIS IS NOT A BILL | Page 2 of 6
Jennifer Washington
CHART 1
Your MONTHLY prescriptions for covered Part D drugs: APRIL 2022
Totals for the month of April 2022
• Your Out-of-Pocket Costs amount is $35.68
• Your Total Drug Costs amount is $220.50
Drug Name, Fill Date,
Pharmacy, Rx#
You
Paid
Plan
Paid
Other
Payments
Drug
Price
Price
Change
Zocor, 40 mg tabs
04/09/22, ABC Pharmacy
Rx# 106663421555, 30 day supply
$17.53
$125.35
$5.00
$147.88
+4%
Atorvastatin
Mavenclad, 10 mg tabs
04/09/22, ABC Pharmacy
Rx# 349000711222, 30 day supply
$18.15
$54.47
$0.00
$72.62
-2%
Fingolimod
$35.68
$179.82
$5.00
$220.50
Totals for the month of
April 2022
Lower Cost
Alternative Drugs
[paid by
SPAP]
CHART 1A
Your prescriptions for drugs covered by your plan’s
Supplemental Drug Coverage: APRIL 2022
Your Supplemental Drug Coverage pays for some drugs not generally covered by Medicare. Any prescriptions you
filled for these drugs this month are listed in the chart below. The amounts paid for these drugs do not count toward
your out-of-pocket costs* or total drug costs.
You
Paid
Plan
Paid
Other
Payments
Sildenafil, 25 mg tabs
04/09/22, ABC Pharmacy
Rx# 106663421555, 30 day supply
$40.00
$27.32
$0.00
Benzonatate, 100 mg caps
04/09/22, ABC Pharmacy
Rx# 349000711222, 30 day supply
$10.00
$7.44
$0.00
Drug Name, Fill Date,
Pharmacy, Rx#
If you have questions, please call Birchwood Medicare Plus at 1-800-222-3333 (TTY 1-888-444-5555),
Monday through Friday from 8 a.m. to 5 p.m. The call is free. For more information, visit www.birchwood.com.
THIS IS NOT A BILL | Page 3 of 6
Jennifer Washington
CHART 2
Your YEARLY spending totals for covered Part D drugs
Totals for the year-to-date
• Your Out-of-Pocket Costs* amount is $447.53
(includes what You Paid plus Other Payments)
• Your Total Drug Costs amount is $774.43
Monthly totals:
April 2022
Year-to-date totals:
Jan – April 2022
You
Paid
Plan
Paid
Other
Payments
Total Drug
Costs
$35.68
$179.82
$5.00
$220.50
$442.53
$326.90
$5.00
$774.43
CHART 3
Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it. This
chart helps you understand what stage you’re in now and when you’ll move to the next stage.
Year-to-date totals:
Jan – April 2022
Out-of-pocket costs
Total drug costs
Stage 1:
Yearly
Deductible
lasts until your
out-of-pocket costs
reach $435
You’re in
Stage 2:
Initial
Coverage
$442.53
$774.43
Stage 3:
Coverage
Gap
Stage 4:
Catastrophic
Coverage
starts when
total drug costs
reach $4,130
starts when your
out-of-pocket costs
reach $6,650
You’re in Stage 2: Initial Coverage
What happens next?
• During 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.
• You generally stay in this stage until your
year-to-date total drug costs reach $4,130.00. As
of 04/30/22, your year-to-date total drug costs were
$774.43.
Once you have an additional $3,355.57 in total
drug costs, you move to the next payment stage
(Stage 3: Coverage Gap).
If you have questions, please call Birchwood Medicare Plus at 1-800-222-3333 (TTY 1-888-444-5555),
Monday through Friday from 8 a.m. to 5 p.m. The call is free. For more information, visit www.birchwood.com.
Jennifer Washington
THIS IS NOT A BILL | Page 4 of 6
CHART 4
Changes to our Drug List that affect drugs you take
We may make changes to our Drug List during the year, like adding new drugs; removing drugs; changing coverage
restrictions; or moving drugs from one cost-sharing tier to another. The information below provides updates that
affect plan-covered prescriptions you filled in 2022.
Zocor, 40 mg tabs
Generic replacement
• Beginning June 1, 2022, the brand-name drug Zocor will be removed from our Drug List. We will add a new
generic version of Zocor to the Drug List (it is called Simvastatin).
Understanding these changes
• Generic replacement: This means your
brand-name drug was removed from our Drug List
because a generic version is available, in a lower
cost-sharing tier.
How much will you pay?
The amount you’ll pay depends on which drug payment
stage you’re in when you fill the prescription. To find out
how much you’ll pay, call Birchwood Member Services
at 1-800-222-3333 (TTY 1-888-444-5555).
THIS IS NOT A BILL | Page 5 of 6
Jennifer Washington
GLOSSARY
Terms and Definitions
Out-of-pocket costs include:
• What you paid when you fill/refill a covered
Part D prescription
• Any other payments for your drugs made by family
or friends
• Any other payments made for your drugs by Indian
Health Service; AIDS drug assistance programs; most
charities; and most State Pharmaceutical Assistance
Programs (SPAPs)
Out-of-pocket costs DON’T include
payments made for:
• Plan premiums
• Drugs not covered by our plan
• Non-Part D drugs (like drugs you get during a
hospital stay)
• Drugs covered by our plan’s Supplemental Drug
Coverage
• Prescriptions filled at a non-network pharmacy that
doesn’t meet our out-of-network pharmacy access
policy
• Payments made for your drugs by employer or union
health plans; some government-funded programs
(including TRICARE and the Veteran’s Administration);
Worker’s Compensation; and some other programs
You Paid
This is the amount you paid out-of-pocket for each
drug. It includes any payments for your drugs made by
family or friends.
Plan Paid
This is the amount Birchwood Medicare Plus paid for
each drug.
Other Payments
This shows any payments made by other programs
or organizations, including 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).
See the next page
for places to get
help & more
information about
your options.
About Coverage Stages
• Stage 1: Yearly Deductible
You start in this payment stage each calendar year. In this stage, you pay the full cost of your drugs.
You generally stay in this stage until you’ve paid the amount of your deductible ($435.00).
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date total drug costs reach $4,130.00.
• Stage 3: Coverage Gap
In this stage, you pay 25% of the cost of your generic or brand-name drugs.
You generally stay in this stage until your year-to-date out-of-pocket costs reach $6,650.00.
• Stage 4: Catastrophic Coverage
In this stage, for covered drugs you pay $2 (generic)/$5 (brand) or 5% of the cost, whichever is greater.
You generally stay in this stage for the rest of the calendar year (through December 31, 2022).
If you have questions, please call Birchwood Medicare Plus at 1-800-222-3333 (TTY 1-888-444-5555),
Monday through Friday from 8 a.m. to 5 p.m. The call is free. For more information, visit www.birchwood.com.
Jennifer Washington
THIS IS NOT A BILL | Page 6 of 6
Important things to know about your drug coverage
and your rights
See mistakes or have questions?
If you have questions, see mistakes, or suspect
fraud, call us at Birchwood Member Services
at 1-800-222-3333 (TTY 1-888-444-5555). You
can also find answers to many questions online
at www.birchwood.com. Or, call Medicare at
1-800-MEDICARE (1-800-633-4227). TTY users can
call 1-877-486-2048.
You can also call your State Health Insurance
Assistance Program (SHIP). The name and phone
numbers for your state SHIP are in Chapter 2,
Section 3 of your Evidence of Coverage.
Get help with your options
Here are some things you can do to help you and your
doctor manage any changes in coverage:
• Call Birchwood Member Services to ask for a list
of covered drugs that treat the same medical
condition. This list can help your doctor to find a
covered drug that might work for you and have
fewer restrictions or a lower cost.
• You and your doctor can ask us to make an
exception for you. This means asking us to agree
that the change in coverage or cost-sharing tier of a
drug doesn’t apply to you. To learn how to ask for an
exception, see Chapter 7 in the Evidence of Coverage,
“What to do if you have a problem or complaint.”
Get more details in the Evidence of Coverage
The Evidence of Coverage is our plan’s benefits booklet.
It explains your drug coverage and the rules you
need to follow to use your coverage. To get a copy
of the Evidence of Coverage in your mail or email,
call Birchwood Member Services at 1-800-222-3333
(TTY 1-888-444-5555). You can also get this document
online at www.birchwood.com.
Where to go for help with coverage
problems
Your Evidence of Coverage explains 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)
Your right to appeal
When we decide whether a drug is covered 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).
Medicare sets the rules for how coverage decisions
and appeals are handled. These are legal procedures
and the deadlines are important. The process can
be expedited if your doctor tells us that your health
requires a quick decision.
Get help paying for your drug coverage
“Extra Help” from Medicare. If you meet certain
income and resource limits, you may qualify for Extra
Help. This program helps pay for your Medicare drug
coverage costs, such as plan premiums, deductibles,
and costs when you fill your prescriptions. To see if
you qualify for Extra Help, complete an application
online at https://secure.ssa.gov/i1020/start. You can
also call Social Security toll-free at 1-800-772-1213
(TTY 1-800-325-0778).
Help from your State Pharmaceutical Assistance
Program. Many states have State Pharmaceutical
Assistance Programs (SPAPs) that help people pay for
prescription drugs based on financial need, age, or
medical condition. Each state has different rules. To find
out if your state has a State Pharmaceutical Assistance
Program, visit Medicare.gov and search for “SPAP.” Or,
check with your local State Health Insurance Assistance
Program (SHIP).
If you have questions, please call Birchwood Medicare Plus at 1-800-222-3333 (TTY 1-888-444-5555),
Monday through Friday from 8 a.m. to 5 p.m. The call is free. For more information, visit www.birchwood.com.
| File Type | application/pdf |
| File Modified | 2022-03-09 |
| File Created | 2021-11-16 |