Appendix B. CY 2025 Part D EOB Exhibit A

EXHIBIT A. Examples of a cover page
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 15, 2025, 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 portrait orientation, using the portrait version of the cover minimizes reader
burden by keeping orientation consistent throughout the document.

•

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

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, 2025

Claims for

March 2025

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-ofPocket 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. If you
participate in the Medicare Prescription Payment Plan, we’ll send you a separate monthly billing statement,
and amounts shown in this EOB might differ from what you paid. Contact us if you have questions or want
more information. Visit Medicare.gov for information about the Medicare Prescription Payment Plan.

•

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
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 on this page.

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, 2025

Claims for

March 2025

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.

Your Medicare Part D Explanation of Benefits (EOB)

1-800-222-3333
1-888-444-5555 for TTY/TDD only

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.

Or visit our website:
www.birchwood.com

•

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. If you participate in the Medicare Prescription Payment Plan, we’ll send you a
separate monthly billing statement, and amounts shown in this EOB might differ from what
you paid. Contact us if you have questions or want more information. Visit Medicare.gov for
information about the Medicare Prescription Payment Plan.

•

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 at right..

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 on this page.