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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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