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 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
Example 3: Initial coverage stage, with LIS, and payments from plan and Extra Help
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:
- SECTION 1: Your prescriptions during the past month
- SECTION 2: Your current drug payment stage
- 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 a section above for more details and examples.
Click here for Questions and Answers about Straddle Claims