Eob

Model Part D EOB EXHIBIT D

EXHIBIT D. Definitions for TrOOP and Total Drug Costs for a plan that
offers Supplemental Drug Coverage
The language below shows definitions of Out-of-Pocket Costs and Total Drug Costs for a fictional plan that
offers Supplemental Drug Coverage. This language appears immediately after Chart 2 to help enrollees
understand what their monthly and yearly totals do and do not include.

Out-of-Pocket Costs include:

Total Drug 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)

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

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