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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"

$[insert TrOOP for month] month of [insert name of month], [insert year]

$[insert year-to-date TrOOP] year-to-date (since [insert January, [year] or other date if applicable])		 Your "total drug costs"

$[insert Total Drug Costs for month] month of [insert name of month], [insert year]

$[insert year-to-date Total Drug Costs] year-to-date (since [insert 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.]


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.)"

Navigate the Explanation of Benefits document:



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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; 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; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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