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Explanation of Benefits (EOB) SECTION 1: Your Prescription Purchases During the Past Month

 This section shows details of each of your prescription purchases in the previous month. There could be one or two charts. The first chart will contain prescriptions covered by your plan. The second chart would contain "Bonus" drugs or prescriptions for drugs covered under your plan’s Supplemental Drug Coverage. NOTE: When Chart 2 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 2)."

Also note that "Straddle Claims," purchases that cross you from one stage of your coverage to another, are not stated very clearly in the EOB monthly purchases chart. Click here for Questions and Answers about Straddle Claims

The charts are broken into at least four (4) columns.
The first column contains the drug purchased (name of drug followed by description of strength and form, e.g., "25 mg tabs") and purchase date. If no drugs were purchased, the statement, "No prescriptions for covered Part D drugs this month" will be in column one,
the second column lists what the plan paid on your behalf,
the third column is what you paid (your cost-sharing), and
the fourth column is for other payments made by programs or organizations.

The amounts for "you paid" are the final amounts after other payments (those made by programs, organizations, or other plans).
This example shows the standard format for Chart 1 and is followed by some examples.

CHART 1.
Your Prescriptions for covered Part D drugs.		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
Name of drug followed by followed by quantity, strength, and form, e.g., "25 mg tabs" and the date prescription was filled.

If Section 4 on formulary changes contains a change that applies to a drug listed in Chart 1, plans should insert a note here to alert you that this change has taken place. Example: "NOTE: Beginning on January 1, 2019, step therapy will be required for this drug. See Section 4 for details."		 Amount paid by the plan. Use $0.00 if applicable. Amount. Use $0.00 if applicable. Amount. Use $0.00 if applicable. For each payment, identify the payer as follows. When paid by the Medicare Coverage Gap Discount Program or Extra Help. e.g.: "$5.00 (paid by Medicare Coverage Gap Discount Program)", "$5.00 (paid by ’Extra Help’)". Plan may insert other payers if known.
TOTALS for the month of _____

Your "out-of-pocket costs" amount is $______. (This is the amount you paid this month plus the amount of "other payments" made this month that count toward your "out-of-pocket costs"

Your "total drug costs" amount is $______. (This is the total for this month of all payments made for your drugs by the plan ($____) and you ($____) plus "other payments"($____).)		 Total amount paid by the plan this month; use $0.00 if applicable.

(total for the month)		 Total amount paid by member this month; use $0.00 if applicable.

(total for the month)

If amount is not $0.00, and any of this total does not count toward out-of-pocket costs,the following text will be added: (Of this amount, $_____ counts toward your out-of-pocket costs.)		 Total amount of "other payments" for the month; use $0.00 if applicable.

(total for the month)

If amount is not $0.00, and any payments do not count toward out-of-pocket costs,the following text will be added: (Of this amount, $_____ counts toward your out-of-pocket costs.)
Year-to-date totals
[insert beginning date for the period covered by year-to-date, e.g., "1/1/23"] through [insert ending date for the month]		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
Your year-to-date amount for "out-of-pocket costs" is $______

Your year-to-date amount for "total drug costs" is $______.

For more about "out-of-pocket costs" and "total drug costs," see Section 3.		 Year-to-date amount of payments made by the plan; use $0.00 if applicable.

(year-to-date total)		 Year-to-date amount paid by the member; use $0.00 if applicable.

(year-to-date total)		 Year-to-date total for "other payments"; use $0.00 if applicable.

(year-to-date total)



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.

CHART 1.
Your Prescriptions for covered Part D drugs
September 2023.		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
{name of first drug} 40 mg tabs
09/01/23, ABC Pharmacy
Rx# 106663421555, 30 day supply

NOTE: Beginning on January 1, 2024, step therapy will be required for this drug. See Section 4 for details.		 $0.00 $45.18 $0.00
{name of second drug} 25 mg caps
09/01/23, ABC Pharmacy
Rx# 106663421555, 30 day supply		 $0.00 $13.80 $0.00
TOTALS for the month of September 2023:

Your "out-of-pocket costs" amount is $58.98. (This is the amount you paid this month ($58.98) plus the amount of "other payments" made this month that count toward your "out-of-pocket costs" ($0.00). see definitions in Section 3.

Your "total drug costs" amount is $58.98. (This is the total for this month of all payments made for your drugs by the plan ($0.00) and you ($58.98) plus "other payments" ($0.00).)		 $0.00
(total for the month)		 $58.98
(total for the month)		 $0.00
(total for the month)
Year-to-date totals
1/1/23 through 9/30/23		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
Your year-to-date amount for "out-of-pocket costs" is $58.98.

Your year-to-date amount for "total drug costs" is $58.98.

For more about "out-of-pocket costs" and "total drug costs," see Section 3.		 $0.00
(year-to-date total)		 $58.98
(year-to-date total)		 $0.00
(year-to-date total)



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.

CHART 1.
Your Prescriptions for covered Part D drugs
September 2023.		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
{name of first drug} inj 100 u/ml
09/01/23, ABC Pharmacy
Rx# 106663421555, 15 day supply		 $107.11 $21.42 $14.28
(paid by "Extra Help")
{name of second drug} 240 mg caps
09/01/23, ABC Pharmacy
Rx# 106663421555, 30 day supply

NOTE: Effective January 1, 2024, this drug will be removed from our drug list. See Section 4 for details.		 $6.60 $1.32 $2.26
(paid by "Extra Help")
{name of third drug} 150 mg tabs
09/01/23, ABC Pharmacy
Rx# 106663421555, 30 day supply		 $326.90 $10.00 $43.59
(paid by "Extra Help")

$65.38
(paid by Worker’s Compensation)
{name of fourth drug} 50 mg tabs
09/01/23, ABC Pharmacy
Rx# 106663421555, 30 day supply

NOTE: Effective January 1, 2024, this drug will be moved from cost-sharing tier 2 to a higher cost-sharing tier (tier 3). See Section 4 for details.		 $60.17 $12.03 $8.02
(paid by "Extra Help")
{name of fifth drug}
09/14/23, ABC Pharmacy
Rx# 106663421555, 15 day supply		 $107.11 $21.42 $14.28
(paid by "Extra Help")
TOTALS for the month of September 2023:

Your "out-of-pocket costs" amount is $148.62. (This is the amount you paid this month ($66.19) plus the amount of "other payments" made this month that count toward your "out-of-pocket costs" ($82.43). see definitions in Section 3.

Your "total drug costs" amount is $821.89. (This is the total for this month of all payments made for your drugs by the plan ($607.89) and you ($66.19) plus "other payments" ($147.81).)		 $607.89
(total for the month)		 $66.19
(total for the month)		 $147.81
(total for the month)

(Of this amount, $82.43 counts toward your "out-of pocket" costs. See definitions in Section 3.)
Year-to-date totals
1/1/23 through 9/30/23		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
Your year-to-date amount for "out-of-pocket costs" is $690.80.

Your year-to-date amount for "total drug costs" is $2,136.26.

For more about "out-of-pocket costs" and "total drug costs," see Section 3.		 $1,314.70
(year-to-date total)		 $445.20
(year-to-date total)		 $376.36
(year-to-date total)

(Of this amount, $245.60 counts toward your "out-of pocket costs." See definitions in Section 3.)



Example 3: Chart 2 for prescriptions covered by Supplemental Drug Coverage

Showing a separate chart for prescriptions covered under the plan’s Supplemental Drug Coverage 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 2 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 2)."

This chart shows your prescriptions for drugs that are not generally covered by Medicare. These drugs are covered for you under our plan’s Supplemental Drug Coverage. generally covered by Medicare.

CHART 2.
Your prescriptions for drugs covered by our plan’s Supplemental Drug Coverage
September 2023.		 Plan paid You paid Other payments (made by programs or organizations; see Section 3)
{name of first bonus drug} 0.5 mg
09/01/23, ABC Pharmacy
Rx# 106663421555, 30 day supply		 $2.80 $5.00 $0.00
Totals for the month of September 2023          $2.80                    $5.00                    $0.00

These payments do not count toward your "out-of-pocket costs" or your "total drug costs" because they are for drugs that are not generally covered by Medicare. (See definitions in Section 3.)


Drug Notes

As you can see in the example charts above, formulary changes will be noted for those drugs affected. Some examples of notes are:
  • Drug Utilization (Usage) Management changes Ex: Beginning on January 1, 2023, step therapy will be required for this drug. See Section 4 for details.

  • Drug Removal from Formulary Ex: Effective January 1, 2023, this drug will be removed from our drug list. See Section 4 for details.

  • Cost-Sharing Tier changes Ex: Effective January 1, 2023, this drug will be moved from cost-sharing tier 2 to a higher cost-sharing tier (tier 3). See Section 4 for details.
These notes are described in more detail in Section 4 of the Explanation of Benefits document.

Also note that "Straddle Claims," purchases that cross you from one stage of your coverage to another, are not stated very clearly in the EOB monthly purchases chart. Click here for Questions and Answers about Straddle Claims

Navigate the Explanation of Benefits document:



Click on a section above for more details and examples.
Click here for Questions and Answers about Straddle Claims


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