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Understanding Your Explanation of Benefits (EOB)

:: When do people get an EOB?
:: What does an EOB include?
:: What should a person who gets an EOB do with the information?
:: Explanation of Benefits (EOB) Document Sections

What is an Explanation of Benefits (EOB)?

  • An EOB is a statement beneficiaries get for every month in which they fill a prescription using their Medicare Part D prescription drug plan.

  • An EOB is also mailed to beneficiaries who have a change in coverage of a drug they take or if someone has changed plans and has a transfer of prescription cost totals from one plan to another.
The EOB isn’t a bill. It provides detailed information about the drug plan coverage you have used to date. It also helps you understand how your prescription drug coverage applies to the prescriptions you fill.


When do people get an EOB?

You should get an Explanation of Benefits (EOB) by the end of the month following the month you fill a prescription using your Medicare Part D prescription drug plan.


What does an EOB include?

Explanation of Benefits (EOB) includes the following information:
  • A summary of the claims (drug purchases) processed since your last EOB

  • A summary of your year-to-date costs in the plan and information about the your current drug payment stage (for example, the deductible, initial coverage, the coverage gap, or catastrophic coverage) and your total out-of pocket costs and total drug costs

  • A record of your total out-of-pocket costs and total drug costs transferred from your previous plan(s) (if a person changed plans during the year)

  • Any adjustments (such as for a reversed claim or a wraparound payment by a supplemental payer) or corrections (such as a clerical error) to your total out-of-pocket costs and total drug costs that aren’t shown in a previous EOB (if there are any adjustments)

  • Any updates to the drug plan’s formulary that will affect the drugs you are currently taking (if there are any updates)

  • Resources for more information including the plan’s contact information and what you can do if you disagree with the accuracy of your EOB or a coverage decision the plan made (see: How to Request a Coverage Determination, Exception, or File an Appeal)



What should a person who gets an EOB do with the information?

Check the Explanation of Benefits (EOB) for mistakes
You should keep your EOBs for your records. Reviewing the EOB for accuracy is important. You should save your pharmacy receipts when you fill prescriptions to check against the claims listed on your EOB. If you have questions or find mistakes, you should contact your plan. If you suspect Medicare fraud, you should call the Medicare Drug Integrity Contractor at 1-877-7SAFERX (1-877-772-3379).

Monitor progress through the plan’s phases
The EOB provides a monthly and year-to-date summary of your drug plan costs with a breakdown of the drug plan costs paid during each drug payment stage (for example, the deductible, initial coverage, the coverage gap, or catastrophic coverage) . The EOB also helps you know about how much you have left to pay in your current drug payment stage before moving to the next stage.

Check for updates to the plan’s formulary (list of covered drugs)
Plans may remove drugs from their formularies, change the formulary tier on which a drug is placed, and/or add rules about whether and when the plan covers certain drugs during the year. Plans whose formularies are changing will include a section in the EOB when the changes to the formulary affect the coverage or cost of the drugs you take. Some changes won’t affect your coverage for a particular drug for the rest of the year. Other changes are effective 60 days after you receive notice of the change (for example, listed in this section of the EOB or sent a separate formulary change notice).

This section may also provide a list of other covered drugs that you may be able to take instead. You should talk to your doctor to find out if any of the other possible drugs are right for you. The EOB includes more information on what you can do if you have a question about any updates to your plan’s formulary.


Explanation of Benefits (EOB) Document Sections

The Explanation of Benefits document is broken into sections as follows:
: : 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"
: : SECTION 4: Updates to the plan's Drug List that will 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
: : FAQs: Questions and Answers about Explanation of Benefits


Click on the title above or the navigation to the left for more details and examples for each section.

Click here for Questions and Answers about Straddle Claims
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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.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.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • 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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