CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D E

2022 Part D EOB Exhibit A

1

EXHIBIT A.

Examples of a cover page

(shown in landscape and portrait versions)

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 5, 2022, 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 landscape orientation, using landscape orientation for the cover minimizes burden on the readers by keeping a consistent orientation throughout the document.

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

October 8, 2009 To:

April 5, 2022 Jane Doe

1500 Main Street

Anytown, MD 21201

Your member numbers are:

{insert member ID numbers and any other applicable reference numbers}

Birchwood Medicare Plus (HMO) is operated by Birchwood Health Corporation (1500 Springfield Drive, Anytown, PA 18500).

Need large print or anothe r format?

To get this material in other formats, or ask for language translation services, call Birchwood Member Services (the number is on this page).

For language s othe r than English:

Español 1-800-331-2345 (Spanish)

Русский 1-800-331-5678 (Russian)

tiếng Việt 1-800-331-7777 (Vietnamese)

Your Monthly Prescription Drug Summary

For March 2022

This summary is your “Explanation of Benefits” (EOB) for your Medicare prescription drug coverage (Part D). Please review this summary and keep it for your records. (This is not a bill.)

Here are the sections in this summary:

SECTION 1. Your prescriptions during the past month SECTION 2. Which “drug payment stage” are you in?

SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and definitions) SECTION 4. Updates to the plan’s Drug List that affect drugs you take

SECTION 5. If you see mistakes on this summary or have questions, what should you do?

SECTION 6. Important things to know about your drug coverage and your rights

Birchwood Member Services

If you have questions or need help, call us. We are available Monday through Friday from 8 am to 5 pm. Calls to these numbers are free.

1-800-222-3333 TTY Users only: 1-888-444-5555

Fax: 1-800-111-7788

On the Web at: http://www.birchwood.com

2022 Part D EOB Exhibit A 3

April 5, 2022

Birchwood Medicare Plus (HMO) is operated by Birchwood Health Corporation (1500 Springfield Drive, Anytown, PA 18500).

Your member numbers are:

[Insert member ID numbers and any other applicable reference numbers]

Jane Doe

1500 Main Street

Anytown, MD 21201

Your Monthly Prescription Drug Summary

For March 2022

This summary is your “Explanation of Benefits” (EOB) for your Medicare prescription drug coverage (Part D). Please review this summary and keep it for your records. (This is not a bill.)

Here are the sections in this summary:

SECTION 1. Your prescriptions during the past month SECTION 2. Which “drug payment stage” are you in?

SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and definitions)

SECTION 4. Updates to the plan’s Drug List that affect drugs you take

SECTION 5. If you see mistakes on this summary or have questions, what should you do? SECTION 6. Important things to know about your drug coverage and your rights

Need large print or another format?

To get this material in other formats, or ask for language translation services, call Birchwood Member Services (the number is on this page).

For languages other than English:

Español 1-800-331-2345 (Spanish)

Русский 1-800-331-5678 (Russian)

tiếng Việt 1-800-331-7777 (Vietnamese)

Birchwood Member Services

If you have questions or need help, call us. We are available Monday through Friday from 8 am to 5 pm. Calls to these numbers are free.

1-800-222-3333

TTY Users only: 1-888-444-5555

Fax: 1-800-111-7788

On the Web at: http://www.birchwood.com