Explanation of Benefits (EOB): Your Prescription Purchases During the Past Month

Chart 1 Your MONTHLY prescriptions for covered Part D drugs - standard format

This example shows the standard format for Chart 1 and is followed by some examples.

Example 1 Deductible payment stage

This example shows what your Explanation of Benefits (EOB) may look like if you are in the deductible phase of your Medicare Part D Plan coverage. Note that the values in the "Plan Paid" column are $0.00. This is because you are 100% responsible for your medication costs during the deductible phase of your coverage.

If you are receiving "Extra Help" with your medication costs, you will not have a deductible phase to your plan coverage even if the design of your plan includes a deductible phase.

Example 2: Initial coverage stage

This example show what your Explanation of Benefits (EOB) might look like if you are in the initial coverage phase of your Medicare Part D coverage. This phase can include, payments from plan, from Extra Help, and from other organizations on your behalf.

Example 3: Chart 1A for prescriptions covered by Supplemental Drug Coverage

A separate chart is shown for non-Part D prescriptions covered under the plan’s Supplemental Drug Coverage. This helps reduce potential confusion by emphasizing that payments for these prescriptions do not count toward members’ Out-of-Pocket Costs or Total Drug Costs.

NOTE: When Chart 1A is included in an EOB, the following sentence is added to the first bulleted point in the introductory section of Chart 1: "(Prescriptions for drugs covered by our plan’s Supplemental Drug Coverage are shown separately in Chart 1A)."

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.