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Explanation of Benefits (EOB) SECTION 3: Your "out-of-pocket costs" and "total drug costs"
This section shows details and definitions of your "out-of-pocket costs" and "total drug costs"
The chart is broken into two (2) columns. The first column contains your "out-of-pocket costs" and the second column lists your "total drug costs". Both are followed by definitions to help you understand what is included and not include in each total.
Your "out-of-pocket costs"
$[TrOOP for month] month of [name of month], [year]
$[year-to-date TrOOP] year-to-date (since [January, [year] or other date if applicable]) |
Your "total drug costs"
$[Total Drug Costsfor month] month of [name of month], [year]
$[year-to-date Total Drug Costs] year-to-date (since [January, [year] or other date if applicable]) |
DEFINITION:
"Out of pocket costs" includes:
• What you pay when you fill or refill a prescription for a covered Part D drug. (This includes payments for your drugs, if any, that are made by family or friends.)
• Payments made for your drugs by any of the following programs or organizations: "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).
It does not include:
• Payments made for: a) plan premiums, b) drugs not covered by our plan, c) non-Part D drugs (such as drugs you receive during a hospital stay), [insert if applicable: d) drugs covered by our plan’s Supplemental Drug Coverage, e) drugs obtained at a non-network pharmacy that does not meet our out-of-network pharmacy access policy.]
• Payments made for your drugs by any of the following programs or organizations: employer or union health plans; some government-funded programs, including TRICARE and the Veteran’s Administration; Worker’s Compensation; and some other programs. |
DEFINITION:
"Total drug costs" is the total of all payments made for your covered Part D drugs. It includes:
• What the plan pays.
• What you pay.
• What others (programs or organizations) pay for your drugs.
[Insert only if the plan offers coverage of supplemental drugs as part of an enhanced alternative benefit: NOTE: Our plan offers Supplemental Drug Coverage for some drugs not generally covered by Medicare. If you have filled any prescriptions for these drugs this month, they are listed in a separate chart (Chart 2) in Section 1. The amounts paid for these drugs do not count toward your out-of-pocket costs or total drug costs.] |
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Learn more. Medicare has made the rules about which types of payments count and do not count toward "out-of-pocket costs" and "total drug costs." The definitions on this page give you only the main rules. For details, including more about "covered Part D drugs," see the Evidence of Coverage, our benefits booklet (for more about the Evidence of Coverage, see Section 6).
Notes: If you switched plans during the year, your TrOOP and Total Drugs costs will be shown in this chart using the following text:
TrOOP: "(This total includes $[insert the TrOOP balance transferred from prior plan] in out-of-pocket costs from when you were in a different plan earlier this year.)"
Total Drug Costs: "(This total includes $[insert the Total Drug Costs balance transferred from prior plan] in total drug costs from when you were in a different plan earlier this year.)"
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