CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D E

2022 Part D EOB Exhibit A

1

EXHIBIT A.
Examples of a cover page
(shown in landscape and portrait versions)
The examples in this exhibit illustrate the overall look for the cover page of the Model Part D EOB.
This example is for a Part D EOB to be sent out April 5, 2022, for a fictional plan called “Birchwood
Medicare Plus.”
In this exhibit, the same cover is shown in portrait orientation and landscape orientation. Plans may
use either of these.
•

Since the rest of the EOB is in landscape orientation, using landscape orientation for the cover
minimizes burden on the readers by keeping a consistent orientation throughout the document.

•

The portrait version of the cover is included for optional use, with the member’s name and
address positioned for mailing in a window envelope.

2022 Part D EOB Exhibit A

2

Your Monthly Prescription Drug Summary

October 8, 2009
To:

For March 2022

April 5, 2022
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.)

Jane Doe
1500 Main Street
Anytown, MD 21201
Your member numbers are:
{insert member ID numbers and any other
applicable reference numbers}
Birchwood Medicare Plus (HMO) is operated
by Birchwood Health Corporation (1500
Springfield Drive, Anytown, PA 18500).
Need large print or another
format?
To get this material in other formats, or ask
for language translation services, call
Birchwood Member Services (the number is
on this page).
For languages other than English:

Español 1-800-331-2345
Русский
tiếng Việt

(Spanish)

1-800-331-5678 (Russian)
1-800-331-7777 (Vietnamese)

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 TTY Users only: 1-888-444-5555
Fax: 1-800-111-7788
On the Web at: http://www.birchwood.com

2022 Part D EOB Exhibit A

3

Your member numbers are:
[Insert member ID numbers and any other
applicable reference numbers]

April 5, 2022
Birchwood Medicare Plus (HMO) is operated
by Birchwood Health Corporation (1500
Springfield Drive, Anytown, PA 18500).

Jane Doe
1500 Main Street
Anytown, MD 21201

Your Monthly Prescription Drug Summary
For March 2022
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

Need large print or another
format?
To get this material in other formats, or ask
for language translation services, call
Birchwood Member Services (the number is
on this page).

For languages other than English:

Español 1-800-331-2345
Русский
tiếng Việt

(Spanish)

1-800-331-5678 (Russian)
1-800-331-7777 (Vietnamese)

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
TTY Users only: 1-888-444-5555
Fax: 1-800-111-7788
On the Web at: http://www.birchwood.com