q1medicare.com
Powered by Q1Group LLC
A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu ☰
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search ⌕
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search ⌕

Explanation of Benefits (EOB): Your "out-of-pocket costs" and "total drug costs"

 Your out-of-pocket costs are shown above Chart 1 in the grey box. Your year-to-date costs are shown in Chart 2.

Out-of-Pocket Costs include:
• What you paid when you fill/refill a covered Part D prescription
• Any payments for your drugs made by family or friends
• Any payments made for your drugs by Extra Help from Medicare, employer or union health plans, TRICARE, Indian Health Service, AIDS drug assistance programs, charities, and most State Pharmaceutical Assistance Programs (SPAPs)

Out-of-Pocket Costs DON’T include payments made for:
• Plan premiums
• Drugs not covered by our plan
• Non-Part D drugs (like drugs you get during a hospital stay)
• Drugs covered by certain other programs, such as the Veteran’s Administration or Worker’s Compensation
• Manufacturer Discount Program
• Selected Drug subsidy
• Drugs covered by our plan’s Supplemental Drug Coverage listed in Chart 1A


Example 1: 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. Your out-of-pocket costs and total drug costs are shown in the grey box above the chart.

Chart 1 Your MONTHLY prescriptions for covered Part D drugs - Example Initial Coverage stage



Chart 2: Your YEARLY spending totals for covered Part D drugs

Chart 2 shows your year-to-date Medicare Part D drug spending.

Chart 2 is broken into five (5) columns.

(1) Monthly and Yearly rows are shown.

(2) You Paid is the amount you paid out-of-pocket for each drug. It includes any payments for your drugs made by family or friends. Beginning in 2025, if you participate in the Medicare Prescription Payment Plan, we’ll send you a separate monthly billing statement, and the amounts here might differ from what you paid.

(3) Plan Paid lists what the plan paid on your behalf.

(4) Other Payments shows any payments not included in the “You Paid” and “Plan Paid” columns, such as those made by Extra Help from Medicare, employer or union health plans, TRICARE, Indian Health Service, AIDS drug assistance programs, Manufacturer Discount Program, charities, and State Pharmaceutical Assistance Programs (SPAPs). Some of these payments may not count towards your Out-of-Pocket Costs.

(5) 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 other programs or organizations pay for your drugs


Example 2: Deductible payment stage, no payments from plan or others


Chart 2 Your YEARLY spending totals for covered Part D drugs - Example non-LIS



Example 3: Initial coverage stage, with LIS, and payments from plan and Extra Help



Chart 2 Your YEARLY spending totals for covered Part D drugs - Example LIS


The charts on this page are provided in the model documents released by the Centers for Medicare and Medicaid Services (CMS).

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:



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


Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs




© Q1Group LLC 2005 - 2024  



Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • 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.
  • 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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.
.