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Explanation of Benefits (EOB): Important things to know about your drug coverage and your rights.

 This section shows details some your rights in the Medicare Part D program and will read as follows

Get help with your options

Here are some things you can do to help you and your prescriber manage any changes in coverage:

Call [insert plan name] Member Services or visit our website to ask for a list of covered drugs that treat the same medical condition. This list can help your prescriber to find a covered drug that might work for you and have fewer restrictions or a lower cost.

You and your prescriber can ask us to make an exception for you. This means asking us to agree that the change in coverage or cost-sharing tier of a drug shouldn’t apply to you. To learn how to ask for an exception, see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] in the Evidence of Coverage, “What to do if you have a problem or complaint.”


Get help paying for your drug coverage

"Extra Help" from Medicare. If you meet certain income and resource limits, you may qualify for Extra Help. This program helps pay for your Medicare drug coverage costs, such as plan premiums, deductibles, and costs when you fill your prescriptions. To see if you qualify for Extra Help, complete an application online at https://secure.ssa.gov/i1020/start. You can also call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Help from your State Pharmaceutical Assistance Program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. To find out if your state has a State Pharmaceutical Assistance Program, visit Medicare.gov and search for "SPAP." Or, check with your local State Health Insurance Assistance Program (SHIP).

Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan can help you manage your drug costs by spreading them out during the year as monthly payments. This program is available to anyone with Medicare Part D and can be especially helpful to people with high cost sharing earlier in the plan year. Contact us or visit Medicare.gov to learn more about this program.


Get help with drug coverage or payment problems

Your Evidence of Coverage has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for:

[MA-PD insert: Chapter 7.] [PDP insert: Chapter 5.] Asking the plan to pay its share of a bill you have received for covered services or drugs.

[MA-PD insert: Chapter 9.] [PDP insert: Chapter 7.] What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

Q1Medicare Note: see: appeals level chart overview.

Here are things to keep in mind:
  • When we decide whether a drug is covered and how much you pay, it’s called a "coverage decision." If you disagree with our coverage decision, you can appeal our decision (see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the Evidence of Coverage).
  • Medicare has set the rules for how coverage decision and appeal are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.



Get more details in the Evidence of Coverage [if EOB is for a member with LIS, insert "and LIS Rider"

The Evidence of Coverage is our plan’s benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage.

To get a copy of the Evidence of Coverage in your mail or email, call [insert plan name] Member Services at [insert Member Services phone number] (TTY [insert TTY number]). You can also get this document online at [insert plan website URL]

[If EOB is for a member with LIS, insert: Your LIS Rider ("Evidence of Coverage Rider for People Who Get Extra Help Paying for their Prescriptions") is a short separate document that tells what you pay for your prescriptions.]


Your right to appeal

When we decide whether a drug is covered and how much you must pay, it’s called a “coverage decision.” If you disagree with our coverage decision, you can appeal (see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the Evidence of Coverage).

Medicare sets the rules for how coverage decisions and appeals are handled. These are legal procedures and the deadlines are important. The process can be expedited if your prescriber tells us that your health requires a quick decision.

Navigate the Explanation of Benefits document:



Click on a section above for more details and examples.
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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.
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