CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In

Page 1 of 6

PO Box 789

Anytown, USA 12345-6789

THIS IS NOT A BILL

JENNIFER WASHINGTON 123 EXAMPLE STREET

APARTMENT A

ANYTOWN, USA 12345-6789

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 out-of-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.

• 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

1-800-111-7788 fax

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 shown on this page.

CHART 1

Your MONTHLY prescriptions for covered Part D drugs: APRIL 2022

Totals for the month of April 2022

• Your Out-of-Pocket Costs amount is $35.68

• Your Total Drug Costs amount is $220.50

Drug Name, Fill Date, Pharmacy, Rx#	You Paid	Plan Paid	Other Payments	Drug Price	Price Change	Lower Cost Alternative Drugs
Zocor, 40 mg tabs	$17.53	$125.35	$5.00	$147.88	+4%	Atorvastatin
04/09/22, ABC Pharmacy Rx# 106663421555, 30 day supply			[paid by SPAP]
Mavenclad, 10 mg tabs	$18.15	$54.47	$0.00	$72.62	-2%	Fingolimod
04/09/22, ABC Pharmacy
Rx# 349000711222, 30 day supply
Totals for the month of April 2022	$35.68	$179.82	$5.00	$220.50

CHART 1A

Your prescriptions for drugs covered by your plan’s Supplemental Drug Coverage: APRIL 2022

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
Sildenafil, 25 mg tabs 04/09/22, ABC Pharmacy Rx# 106663421555, 30 day supply	$40.00 $10.00	$27.32	$0.00
Benzonatate, 100 mg caps 04/09/22, ABC Pharmacy Rx# 349000711222, 30 day supply		$7.44	$0.00

CHART 2

Your YEARLY spending totals for covered Part D drugs

Totals for the year-to-date

• Your Out-of-Pocket Costs* amount is $447.53

(includes what You Paid plus Other Payments)

• Your Total Drug Costs amount is $774.43

	You Paid	Plan Paid	Other Payments	Total Drug Costs
Monthly totals: April 2022	$35.68	$179.82	$5.00	$220.50
Year-to-date totals: Jan – April 2022	$442.53	$326.90	$5.00	$774.43

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’re in now and when you’ll move to the next stage.

Year-to-date totals: Stage 1: Yearly Jan – April 2022 Deductible		You’re in Stage 2: Initial Coverage	Stage 3: Stage 4: Coverage Catastrophic Gap Coverage
Out-of-pocket costs	lasts until your out-of-pocket costs reach $435	$442.53	starts when total drug costs reach $4,130	starts when your out-of-pocket costs reach $6,650
Total drug costs		$774.43

What happens next?

Once you have an additional $3,355.57 in total drug costs, you move to the next payment stage (Stage 3: Coverage Gap).

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-to-date total drug costs reach $4,130.00. As of 04/30/22, your year-to-date total drug costs were

$774.43.

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 2022.

Understanding these changes

• Generic replacement: This means your

brand-name drug was removed from our Drug List because a generic version is available, in a lower cost-sharing tier.

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 1-888-444-5555).

GLOSSARY

Terms and Definitions

Out-of-pocket costs include:

• What you paid when you fill/refill a covered Part D prescription

• Any other payments for your drugs made by family or friends

• Any other payments made for your drugs by Indian Health Service; AIDS drug assistance programs; most 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 our plan’s Supplemental Drug Coverage

• Prescriptions filled at a non-network pharmacy that doesn’t meet our out-of-network pharmacy access policy

• Payments made for your drugs by employer or union health plans; some government-funded programs (including TRICARE and the Veteran’s Administration); Worker’s Compensation; and some other programs

You Paid

This is the amount you paid out-of-pocket for each drug. It includes any payments for your drugs made by family or friends.

Plan Paid

This is the amount Birchwood Medicare Plus paid for each drug.

Other Payments

This shows any payments made by other programs or organizations, including Extra Help from Medicare; Medicare’s Coverage Gap Discount Program; Indian Health Service; AIDS drug assistance programs; most charities; and most State Pharmaceutical Assistance Programs (SPAPs).

See the next page for places to get help & more information about your options.

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 ($435.00).

• 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 total drug costs reach $4,130.00.

• Stage 3: Coverage Gap

In this stage, you pay 25% of the cost of your generic or brand-name drugs.

You generally stay in this stage until your year-to-date out-of-pocket costs reach $6,650.00.

• Stage 4: Catastrophic Coverage

In this stage, for covered drugs you pay $2 (generic)/$5 (brand) or 5% of the cost, whichever is greater.

You generally stay in this stage for the rest of the calendar year (through December 31, 2022).

Important things to know about your drug coverage and your rights

Where to go for help with coverage problems

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.

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 have received for covered services or drugs

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

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 7 in the Evidence of Coverage, “What to do if you have a problem or complaint.”

Get more details in the Evidence of Coverage

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 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 our decision (see Chapter 9 of 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.

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).