Appendix B. CY 2025 Part D EOB Exhibit G

The Medicare Advantage and Prescription Drug Program: Part C Explanation of Benefits and Supporting Regulations (CMS-10453) - IRA

Appendix B. CY 2025 Part D EOB Exhibit G

OMB: 0938-1228

Document [pdf]

Download: pdf | pdf

Page 1 of 7

EXHIBIT G. Example of a complete EOB
This exhibit displays a complete EOB for a fictional enrollee. All examples use 2024 benefit parameters1 where
2025 benefit parameters are not yet available and will be updated in the final version.

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

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 Outof-Pocket 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.

If you have questions, please call Birchwood Member Services at 1-800-222-3333 (TTY 1-800-444-5555).
The call is free. For more information, visit www.birchwood.com.

THIS IS NOT A BILL | Page 2 of 8

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 $67
• Your Total Drug Costs amount is $320.50

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

You
Paid

Plan
Paid

Other
Payments

Drug
Price

Price
Lower Cost
Change Alternative Drugs

$47

$200.88

$247.88

[insert name of
lower cost
alternative drug]

$20

$52.62

$72.62

[insert name of
lower cost
alternative drug]

$67

$253.50

$320.50

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 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.

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

If you have questions, please call Birchwood Medicare Plus at 1-800-222-3333 (TTY 1-888-444-5555),
Monday through Friday from 8 a.m. to 5 p.m. The call is free. For more information, visit www.birchwood.com.

THIS IS NOT A BILL | Page 3 of 8

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#

You
Paid

Plan
Paid

Other
Payments

[insert name of first drug], 0.5 mg
03/01/25, ABC Pharmacy
Rx# 106663421555, 30 day supply

$47

$153

Totals for the month of
March 2025

$47

$153

THIS IS NOT A BILL | Page 4 of 8

CHART 2

Your YEARLY spending totals for covered Part D drugs
Your year-to-date Out-of-Pocket Costs amount
is $632 (includes what You Paid plus Other
Payments)
You
Paid

Plan
Paid

Other
Payments

Total
Drug Costs

Monthly totals:
March 2025

$67

$253.50

$320.50

Year-to-date totals:
Jan – March 2025

$632

$329.50

$961.50

You Paid

Out-of-Pocket Costs include:

•

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.

THIS IS NOT A BILL | Page 5 of 8

CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it.
This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to the
next stage.

Year-to-date totals:
Jan – March 2025
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible
lasts until
Out-of-Pocket Costs
reach $545

You’re in
Stage 2:
Initial
Coverage

$632

Stage 3:
Catastrophic
Coverage
starts when
Out-of-Pocket Costs
reach $2,000

You’re in Stage 2: Initial Coverage
During this payment stage, the plan pays its share
of the cost of your drugs and you (or others on
your behalf) pay your share of the cost.
You generally stay in this stage until your year-todate Out-of-Pocket Costs reach $2,000. As of
March 31, 2025 your year-to-date Out-of-Pocket
Costs were $632.

What happens next?
Once you have an additional $1,368 in Out-ofPocket Costs, you move to the next payment
stage (Stage 3: Catastrophic Coverage).

About Coverage Stages
•

Stage 1: Yearly Deductible
You start in this payment stage each calendar year. In this stage, you pay the full cost of your drugs.
You generally stay in this stage until you’ve paid the amount of your deductible ($545).
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, the plan pays all of the cost for your covered Part D drugs. You pay nothing. You generally
stay in this stage for the rest of the calendar year.

THIS IS NOT A BILL | Page 6 of 8

CHART 4

Changes to our Drug List that affect drugs you take
We may make changes to our Drug List during the year, like adding new drugs; removing drugs; changing
coverage restrictions; or moving drugs from one cost-sharing tier to another. The information below provides
updates that affect plan-covered prescriptions you filled in 2025.

[Drug A]
Step therapy
• Starting June 1, 2025 “step therapy” will be required for this drug. This means you’ll be required to try a
different drug first before we’ll cover [Drug A]. This requirement encourages you to try another drug that
costs less but is just as safe and effective as [Drug A]. If this other drug doesn’t work for you, the plan will
then cover [Drug A].

Understanding these changes

How much will you pay?

•

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-222-3333
(TTY 1-800-444-5555).

See the next page for places to get help and more
information about your options.
• You and your doctor may want to consider trying
[Alternate Drug 1] or [Alternate Drug 2]. Both are
on our Drug List and have no coverage
restrictions. They’re used in similar ways as [Drug
A] and they’re on a lower cost-sharing tier.

THIS IS NOT A BILL | Page 7 of 8

Important things to know about your drug coverage and your rights
See mistakes or have questions?

Medicare Prescription Payment Plan

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.

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.

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 drug coverage or payment
problems

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).

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.

File Type	application/pdf
File Title	EXHIBIT G. Example of a complete EOB
Author	CMS
File Modified	2023-11-27
File Created	2023-11-27