Appendix B. CY 2025 Part D EOB Exhibit B

Model Part D EOB EXHIBIT B

EXHIBIT B. Examples that show different versions of Chart 1 (monthly
covered prescriptions), Chart 1A (Supplemental Coverage), and Chart 2
(yearly spending totals)
The examples in this exhibit illustrate some of the main variations in model language for Chart 1, Chart 1A and
Chart 2 of the Model Part D Explanation of Benefits (EOB) for a fictional enrollee. This section shows the
monthly list of prescriptions filled by a plan member and summarizes the monthly and yearly spending totals.
These examples use numbers for the year 2025 and placeholders for the names of drugs. All examples use 2024
benefit parameters 1 where 2025 benefit parameters are not yet available and will be updated in the final version.

Example 1: Deductible payment stage, no payments from plan or others ...........................................................2
Example 2: Initial coverage stage, with LIS, payments from plan and Extra Help or another organization .......3
Example 3: Using a separate chart for Supplemental Drug Coverage .................................................................5
Example 4: Using “notes” on Chart 1 to show changes to the formulary ............................................................7
Examples 5 & 6: Chart 2 for yearly spending totals ............................................................................................9

See the April 4, 2023 Health Plan Management System (HPMS) memorandum titled “Final Contract Year (CY) 2024 Part D Bidding
Instructions.
1

1

Model Part D EOB EXHIBIT B

Example 1: Deductible payment stage, no payments from plan or others
CHART 1

Your MONTHLY prescriptions for covered Part D drugs: March 2025
Totals for the month of March 2025

• Your Out-of-Pocket Costs amount is $220.50
• Your Total Drug Costs amount is $220.50

You
Drug Name, Fill Date,
Paid
Pharmacy, Rx#
[insert name of first drug], 40 mg
tabs
$147.88
03/09/25, ABC Pharmacy
Rx# 106663421555, 30 day supply
[insert name of second drug], 10
mg tabs
$72.62
03/09/25, ABC Pharmacy
Rx# 349000711222, 30 day supply
Totals for the month of
$220.50
March 2025

Plan
Paid
$0

Other
Payments
$0

Drug
Price
$147.88

$0

$0

$72.62

$0

$0

$220.50

Lower Cost
Price
Change Alternative Drugs
+4%

[insert name of
lower cost
alternative drug]

-2%

[insert name of
lower cost
alternative drug]

You Paid

Drug Price

This is the amount you paid for each drug. It
includes any payments for your drugs made by
family or friends. If you participate in the Medicare
Prescription Payment Plan, we’ll send you a
separate monthly billing statement, and the
amounts here might differ from what you paid.

This shows the cost of each drug (including
payments made by you, your plan, and others).

Price Change

This is the amount Birchwood paid for each drug.

This shows how the drug price changed (as a
percentage) from when your prescription was first
filled during the benefit year. You’ll only see a drug
price change when the quantity dispensed was the
same.

Other Payments

Lower Cost Alternative Drugs

This shows any payments not included in the “You
Paid” and “Plan Paid” columns, such as those
made by Extra Help from Medicare, employer or
union health plans, TRICARE, Indian Health
Service, AIDS drug assistance programs,
Manufacturer Discount Program, charities, and
State Pharmaceutical Assistance Programs
(SPAPs). Some of these payments may not count
toward your Out-of-Pocket Costs.

This shows drugs that may be an alternative to the
ones you’re taking now, but with lower cost sharing
or a lower drug price. You may want to ask your
doctor if the lower cost alternative is right for you.

Plan Paid

2

Model Part D EOB EXHIBIT B

Example 2: Initial coverage stage, with LIS, payments from plan and Extra
Help or another organization
CHART 1

Your MONTHLY prescriptions for covered Part D drugs: March 2025
Totals for the month of March 2025
• Your Out-of-Pocket Costs amount is $319.93
• Your Total Drug Costs amount is $836.42

Drug Name, Fill Date,
Pharmacy, Rx#

You
Paid

Plan
Paid

Other
Payments

[insert name of first drug], 40 mg
tabs
03/09/25, ABC Pharmacy
Rx# 106663421555, 30 day supply

$4.50

$122.81

$15.50
(paid by
Extra
Help)

$142.81 +11.2% [insert name of
lower cost
alternative drug]

[insert name of second drug],
240 mg caps
03/12/25, ABC Pharmacy
Rx# 349000711222, 30 day supply

$4.50

$0.18

$5.50
(paid by
Extra
Help)

$10.18

-2%

[insert name of
lower cost
alternative drug]

[insert name of third drug], 150
mg tabs
03/15/25, ABC Pharmacy
Rx# 349000711222, 30 day supply

$11.20

$222.94

$211.73
(paid by
Extra
Help)

$445.87

-8.4%

[insert name of
lower cost
alternative drug]

[insert name of fourth drug], 50
mg tabs
03/15/25, ABC Pharmacy
Rx# 349000711222, 30 day supply

$4.50

$60.22

$15.50
(paid by
Extra
Help)

$80.22

+1.1%

[insert name of
lower cost
alternative drug]

[insert name of fifth drug], 100
u/ml
03/15/25, ABC Pharmacy
Rx# 349000711222, 30 day supply

$4.50

$110.34

$42.50
(paid by
Extra
Help)

$157.34

+2.2%

[insert name of
lower cost
alternative drug]

$29.20

$516.49

$290.73

$836.42

Totals for the month of
March 2025

Drug
Price

Lower Cost
Price
Change Alternative Drugs

3

Model Part D EOB EXHIBIT B

You Paid

Drug Price

This is the amount you paid for each drug. It includes
any payments for your drugs made by family or
friends. If you participate in the Medicare
Prescription Payment Plan, we’ll send you a
separate monthly billing statement, and the amounts
here might differ from what you paid.

This shows the cost of each drug (including
payments made by you, your plan, and others).

Price Change

This is the amount Birchwood paid for each drug.

This shows how the drug price changed (as a
percentage) from when your prescription was first
filled during the benefit year. You’ll only see a drug
price change when the quantity dispensed was the
same.

Other Payments

Lower Cost Alternative Drugs

This shows any payments not included in the “You
Paid” and “Plan Paid” columns, such as those made
by Extra Help from Medicare, employer or union
health plans, TRICARE, Indian Health Service, AIDS
drug assistance programs, Manufacturer Discount
Program, charities, and State Pharmaceutical
Assistance Programs (SPAPs). Some of these
payments may not count toward your Out-of-Pocket
Costs.

This shows drugs that may be an alternative to the
ones you’re taking now, but with lower cost sharing or
a lower drug price. You may want to ask your doctor
if the lower cost alternative is right for you.

Plan Paid

4

Model Part D EOB EXHIBIT B

Example 3:
Using a separate chart for Supplemental Drug Coverage
Example 3 shows a version of Chart 1A, which shows prescriptions covered under the plan’s Supplemental
Drug Coverage. This chart follows Chart 1.
Showing a separate chart for prescriptions covered under the plan’s Supplemental Drug Coverage helps reduce
potential confusion by emphasizing that payments for these prescriptions do not count toward members’ Out-ofPocket Costs or Total Drug Costs.
NOTE: When Chart 1A is included in an EOB, the following sentence is added to the first bulleted point in the
introductory section of Chart 1: “(Prescriptions for drugs covered by our plan’s Supplemental Drug Coverage
are shown separately in Chart 1A).”

5

Model Part D EOB EXHIBIT B
CHART 1A

Your prescriptions for drugs covered by your plan’s Supplemental Drug
Coverage: March 2025
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.
Drug Name, Fill Date,
Pharmacy, Rx#
[insert name of first drug], 0.5
mg
03/01/25, ABC Pharmacy
Rx# 106663421555, 30 day supply
Totals for the month of
March 2025

You
Paid

Plan
Paid

Other
Payments

$47

$153

$0

$47

$153

$0

6

Model Part D EOB EXHIBIT B

Example 4: Using “notes” on Chart 1 to show changes to the formulary
Example 4 shows how explanatory notes are used in Chart 1. These notes can provide additional information
about a prescription, such as notes that highlight general price increases for that drug, or when a payment for a
drug does not count toward Out-of-Pocket Costs, or the drug is only partially covered because it is a compound
drug that includes non-Part D drugs. The plan may also suggest lower-cost alternatives that a member and their
doctor might consider in this section.

Model Part D EOB EXHIBIT B
CHART 1

Your MONTHLY prescriptions for covered Part D drugs: March 2025
Totals for the month of March 2025
• Your Out-of-Pocket Costs amount is $279.25
• Your Total Drug Costs amount is $692.30
Drug Name, Fill Date,
Pharmacy, Rx#
[insert name of first drug], 30 mg
tabs
03/11/25, ABC Pharmacy
Rx# 106663421555, 30 day supply
NOTE: Starting June 1, 2025, step
therapy will be required for this
drug. See Chart 4 for details.

You
Paid

$232.25

Plan
Paid

$232.25

Other
Payments

$0

Drug
Price

$464.50

Lower Cost
Price
Change Alternative Drugs

+1.3%

[insert name of third drug], .5 mg
03/25/25, ABC Pharmacy
Rx# 349000711222, 30 day supply
NOTE: Effective June 1, 2025, this
drug will be moved from costsharing tier 2 to a higher costsharing tier (tier 3). See Chart 4 for
details.

$47

$180.80

$0

$227.80

-2.1%

[insert name of
lower cost
alternative drug]

[insert name of
lower cost
alternative drug]

[NOTE: This example shows only the first part of Chart 1. The rest of the chart is not included.]

Model Part D EOB EXHIBIT B

Examples 5 & 6: Chart 2 for yearly spending totals
Examples 5 and 6 illustrate differences in the wording of the text that explains the yearly total amounts. These
examples are for plan members who have no supplemental drug coverage. Each is in a different payment stage:
•

Example 5 shows a version of Chart 2 for a plan member without LIS who is in the deductible payment
stage. This member receives no payments from the plan or from third parties.

•

Example 6 shows a version of Chart 2 for a plan member with LIS who is in the initial coverage
period. This member receives payments from the plan and from Extra Help (these payments count
toward Out-of-Pocket Costs).

Model Part D EOB EXHIBIT B

Example 5: Deductible payment stage, no payments from plan or others
CHART 2

Your YEARLY spending totals for covered Part D drugs
Your year-to-date Out-of-Pocket Costs amount is
$441 (includes what You Paid plus Other
Payments)

Monthly totals:
March 2025
Year-to-date totals:
Jan – March 2025

You
Paid

Plan
Paid

Other
Payments

Total
Drug Costs

$220.50

$0

$0

$220.50

$441

$0

$0

$441

You Paid

This is the amount you paid for each drug. It includes
any payments for your drugs made by family or
friends. If you participate in the Medicare Prescription
Payment Plan, we’ll send you a separate monthly
billing statement, and amounts here might differ from
what you paid.

Plan Paid
This is the amount Birchwood paid for each drug.

Total Drug Costs

This is the total of all payments made for your covered
Part D drugs. It includes:
• What the plan pays
• What you pay
• What other programs or organizations pay for your
drugs

Other Payments

This shows any payments not included in the “You
Paid” and “Plan Paid” columns, those made by Extra
Help from Medicare, employer or union health plans,
TRICARE, Indian Health Service, AIDS drug
assistance programs, Manufacturer Discount Program,
charities, and State Pharmaceutical Assistance
Programs (SPAPs). Some of these payments may not
count towards your Out-of-Pocket Costs.

Out-of-Pocket Costs include:

What you paid when you fill/refill a covered Part D
prescription
• Any payments for your drugs made by family or
friends
• Any payments made for your drugs by Extra Help
from Medicare, employer or union health plans,
TRICARE, Indian Health Service, AIDS drug
assistance programs, 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 certain other programs, such as
the Veteran’s Administration or Worker’s
Compensation
Manufacturer Discount Program
Selected Drug subsidy
Drugs covered by our plan’s Supplemental Drug
Coverage listed in Chart 1A

Learn more

Medicare made the rules about which types of
payments count toward “Out-of-Pocket Costs” and
“Total Drug Costs.” For more details, see
Birchwood’s Evidence of Coverage benefits
booklet.

Model Part D EOB EXHIBIT B

Example 6: Initial coverage stage, with LIS, and payments from plan and
Extra Help
CHART 2

Your YEARLY spending totals for covered Part D drugs
Your year-to-date Out-of-Pocket Costs amount
is $300 (includes what You Paid plus Other
Payments)
You
Paid

Plan
Paid

Other
Payments

Total
Drug Costs

Monthly totals:
March 2025

$11.50

$220.50

$88.50

$320.50

Year-to-date totals:
Jan – March 2025

$34.50

$661.50

$265.50

$661.50

You Paid

Out-of-Pocket Costs include:

This is the amount you paid for each drug. It includes
any payments for your drugs made by family or
friends. If you participate in the Medicare
Prescription Payment Plan, we’ll send you a
separate monthly billing statement, and amounts
here might differ from what you paid.

•

Plan Paid
This is the amount Birchwood paid for each drug.

Total Drug Costs
This is the total of all payments made for your
covered Part D drugs. It includes:
• What the plan pays
• What you pay
• What other programs or organizations pay for
your drugs

Other Payments
This shows any payments not included in the “You
Paid” and “Plan Paid” columns, those made by Extra
Help from Medicare, employer or union health plans,
TRICARE, Indian Health Service, AIDS drug
assistance programs, Manufacturer Discount
Program, charities, and State Pharmaceutical
Assistance Programs (SPAPs). Some of these
payments may not count towards your Out-of-Pocket
Costs.

What you paid when you fill/refill a covered Part D
prescription
• Any payments for your drugs made by family or
friends
• Any payments made for your drugs by Extra Help
from Medicare, employer or union health plans,
TRICARE, Indian Health Service, AIDS drug
assistance programs, 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 certain other programs, such as
the Veteran’s Administration or Worker’s
Compensation
Manufacturer Discount Program
Selected Drug subsidy
Drugs covered by our plan’s Supplemental Drug
Coverage listed in Chart 1A

Learn more

Medicare made the rules about which types of
payments count toward “Out-of-Pocket Costs” and
“Total Drug Costs.” For more details, see
Birchwood’s Evidence of Coverage benefits
booklet.