Appendix B. CY 2025 Part D EOB Exhibit F

Model Part D EOB EXHIBIT F

EXHIBIT F. Example of “Important things to know about your drug
coverage and your rights” page
The page that follows show an example of the “Important things to know about your drug coverage and your
rights” page in the model Part D EOB.
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 that directs the member to the LIS rider for the details about what they pay for drugs. (In the nonLIS version, members are only directed to the Evidence of Coverage for this information.)

Model Part D EOB EXHIBIT F

Important things to know about your drug coverage and your rights
See mistakes or have questions?
If you have questions, see mistakes, or suspect
fraud, call us at Birchwood Member Services at
1-800-222-3333 (TTY 1-888-444-5555). You can
also find answers to many questions online at
www.birchwood.com. Or, call Medicare at
1-800-MEDICARE (1-800-633-4227). TTY users can
call 1-877-486-2048.
You can also call your State Health Insurance
Assistance Program (SHIP). The name and phone
numbers for your state SHIP are in Chapter 2,
Section 3 of your Evidence of Coverage.

Get help with your options
Here are some things you can do to help you and your
doctor manage any changes in coverage:

• Call Birchwood Member Services to ask for a
list of covered drugs that treat the same
medical condition. This list can help your doctor
to find a covered drug that might work for you and
have fewer restrictions or a lower cost.
• You and your doctor can ask us to make an
exception for you. This means asking us to agree
that the change in coverage or cost-sharing tier of
a drug doesn’t apply to you. To learn how to ask for
an exception, see Chapter 9 in the Evidence of
Coverage, “What to do if you have a problem or
complaint.”

Get help paying for your drug coverage
“Extra Help” from Medicare. If you meet certain
income and resource limits, you may qualify for Extra
Help. This program helps pay for your Medicare drug
coverage costs, such as plan premiums, deductibles,
and costs when you fill your prescriptions. To see if
you qualify for Extra Help, complete an application
online at https://secure.ssa.gov/i1020/start. You can
also call Social Security toll-free at 1-800-772-1213
(TTY 1-800-325-0778).
Help from your State Pharmaceutical Assistance
Program. Many states have State Pharmaceutical
Assistance Programs (SPAPs) that help people pay
for prescription drugs based on financial need, age, or
medical condition. Each state has different rules. To
find out if your state has a State Pharmaceutical
Assistance Program, visit Medicare.gov and search
for “SPAP.” Or, check with your local State Health
Insurance Assistance Program (SHIP).

Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan can help
you manage your drug costs by spreading them out
during the year as monthly payments. This program is
available to anyone with Medicare Part D and can be
especially helpful to people with high cost sharing
earlier in the plan year. Contact us or visit
Medicare.gov to learn more about this program.

Get help with drug coverage or
payment problems
Your Evidence of Coverage explains 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 got for covered services or drugs
• Chapter 9: What to do if you have a problem or
complaint (coverage decisions, appeals,
complaints)

Get more details in the Evidence of
Coverage and “LIS Rider”
The Evidence of Coverage is our plan’s benefits
booklet. It explains your drug coverage and the rules
you need to follow to use your coverage. To get a
copy of the Evidence of Coverage in your mail or
email, call Birchwood Member Services at
1-800-222-3333 (TTY 1-888-444-5555). You can also
get this document online at www.birchwood.com.
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.

Your right to appeal
When we decide whether a drug is covered and how
much you must pay, it’s called a “coverage decision.”
If you disagree with our coverage decision, you can
appeal (see Chapter 9 in the Evidence of Coverage).
Medicare sets the rules for how coverage decisions
and appeals are handled. These are legal procedures
and the deadlines are important. The process can be
expedited if your doctor tells us that your health
requires a quick decision.