CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information

2022 Part D EOB Exhibit F

EXHIBIT F. Example of Sections 5 and 6 (information for reference)
The pages that follow show an example of Sections 5 and 6 of the model Part D EOB. These
sections are:
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
The example in this exhibit is for a fictional MA-PD plan called “Birchwood Medicare Plus.”
It shows a version of the Part D EOB for a plan member with LIS. We chose to show a
version for LIS because it includes additional text in Section 6 that directs the member to the
LIS rider for the details about what he or she pays for his or her drugs. (In the non-LIS
version, members are only directed to the Evidence of Coverage for this information.)
To minimize burden on the readers and keep a consistent layout, the draft revised Part D
EOB maintains a landscape orientation (the cover is the only exception; it can be formatted
either in landscape or portrait). To keep line lengths short enough to be easy to read, pages in
landscape orientation generally use two columns. As shown in the example that follows,
these columns are of equal size for Sections 5 and 6. Having a continuous flow of doublecolumn text for these sections helps minimize the overall length of the document.

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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

If you have questions, call us

Your “Evidence of Coverage” and “LIS Rider” have the
details about your drug coverage and costs

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 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.

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. Your LIS Rider
(“Evidence of Coverage Rider for People Who Get Extra Help
Paying for their Prescriptions”) is a short separate document that
tells what you pay for your prescriptions.
We have sent you a copy of the Evidence of Coverage and LIS
Rider. These documents are 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).
Remember, to get your drug coverage under our plan you must use
pharmacies in our network, except in certain circumstances. Also,
quantity limits and restrictions may apply.
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)

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2022 Part D EOB Exhibit F
Here are things to keep in mind:
• When we decide whether a drug is covered and how much
you 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 has set the rules for how coverage
decisions and appeals are handled. These are legal
procedures and the deadlines are important. The
process can take place if your doctor tells us that
your health requires a quick decision.

800-772-1213 between 7 a.m. and 7 p.m., Monday through
Friday. TTY users should call 1-800-325-0778. You can
also call your State Medicaid Office.
• Help from your state’s pharmaceutical assistance
program. Many states have State Pharmaceutical
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.

Please ask for help if you need it. Here’s how:
• 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 1-800-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. You can also call the Social Security Office at 1CMS-10141

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2022 Part D EOB Exhibit F
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improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
CMS does not discriminate in its programs and activities: To request this form in an accessible format (e.g., Braille, Large
Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting your plan, call: 1-800-MEDICARE.

CMS-10141

OMB Approval No. 0938-0964 (Expires 11/30/2021)