CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information

2022 Part D EOB Exhibit F

EXHIBIT F. Example of Sections 5 and 6 (information for reference)

The pages that follow show an example of Sections 5 and 6 of the model Part D EOB. These sections are:

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

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 in Section 6 that directs the member to the LIS rider for the details about what he or she pays for his or her drugs. (In the non-LIS

version, members are only directed to the Evidence of Coverage for this information.)

To minimize burden on the readers and keep a consistent layout, the draft revised Part D EOB maintains a landscape orientation (the cover is the only exception; it can be formatted either in landscape or portrait). To keep line lengths short enough to be easy to read, pages in landscape orientation generally use two columns. As shown in the example that follows, these columns are of equal size for Sections 5 and 6. Having a continuous flow of double- column text for these sections helps minimize the overall length of the document.

SECTION 5. If you see mistakes on this

summary or have questions, what should you do?

If you have que stions, call us

If something is confusing or doesn’t look right on this monthly prescription drug summary, please call us at Birchwood Member Services (phone numbers are on the cover of this summary). You can also find answers to many questions at our website: http://www.birchwood.com.

What about possible fraud?

Most health care professionals and organizations that provide Medicare services are honest. Unfortunately, there may be some who are dishonest.

If this monthly summary shows drugs you’re not taking, or anything else that looks suspicious to you, please tell us so that we can check into it.

• Call us at Birchwood Member Services (phone numbers are on the cover of this summary).

• Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

SECTION 6. Important things to know about

your drug coverage and your rights

Your “Evidence of Coverage” and “LIS Ride r” have the de tails about your drug coverage and costs

The Evidence of Coverage is our plan’s benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage. 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.

We have sent you a copy of the Evidence of Coverage and LIS Rider. These documents are also available on our website: http://www.birchwood.com. You may also elect to receive the Evidence of Coverage electronically, please contact us if you

would like to change your method of delivery. If you need another copy of either of these, please call us (phone numbers for Birchwood Member Services are on the cover of this summary).

Remember, to get your drug coverage under our plan you must use pharmacies in our network, except in certain circumstances. Also, quantity limits and restrictions may apply.

What if you have problems related to coverage or payme nts for your drugs?

Your Evidence of Coverage has step-by-step instructions that explain 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 have received for covered services or drugs

• Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

Here are things to keep in mind:

• When we decide whether a drug is covered and how much you pay, it’s called a “coverage decision.” If you disagree with our coverage decision, you can appeal our decision (see Chapter 9 of the Evidence of Coverage).

• Medicare has set the rules for how coverage

decisions and appeals are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.

Please ask for help if you need it. Here’s how:

• You can call us at Birchwood Member Services (phone numbers are on the cover of this monthly summary).

• You can call Medicare at 1-800-MEDICARE (1-800-633- 4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

• You can call your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your Evidence of Coverage.

Did you know the re are programs to he lp pe ople pay for the ir drugs?

• “Extra Help” from Medicare. You may be able to get Extra Help to pay for your prescription drug premiums and costs. This program is also called the “low-income subsidy” or LIS. People whose yearly income and resources are below certain limits can qualify for this help. To see if you qualify for getting Extra Help, see Section 7 of your

Medicare & You 2022 handbook or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. You can also call the Social Security Office at 1-

800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778. You can

also call your State Medicaid Office.

• Help from your state ’s pharmace utical assistance program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your Evidence of Coverage.

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CMS does not discriminate in its programs and activities: To request this form in an accessible format (e.g., Braille, Large Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting your plan, call: 1-800-MEDICARE.

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CMS-10141

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