Explanation of Benefits (EOB): Your Prescription Purchases During the Past Month
Chart 1 and Chart 1A show details of each of your prescription purchases in the previous month.Chart 1 contains information about your prescription purchases covered by your plan, these are medications that are on your plan’s formulary. Chart 1A covers your "Bonus" drug purchases, these are prescriptions for non-Part D drugs covered under your plan’s Supplemental Drug Coverage. 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)."
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
Chart 1 is broken into seven (7) columns.
(1) Drug Name, Fill Date, Pharmacy, Rx# contains the drug purchased (name of drug followed by description of strength and form, e.g., "25 mg tabs"), purchase date, days supply, and pharmacy. If no drugs were purchased, the statement, "No prescriptions for covered Part D drugs this month" will be in column one.
(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) Drug Price is the drug price and shows the cost of each drug (including payments made by you, your plan, and others).
(6) Price Change shows how the drug price changed (as a percentage) from when your prescription was first filled during the benefit year. You’ll only see a drug price change when the quantity dispensed was the same.
(7) Lower Cost Alternative Drugs shows drugs that may be an alternative to the ones you’re taking now, but with lower cost sharing or a lower drug price. You may want to ask your prescriber if the lower cost alternative is right for you.
The amounts for "you paid" are the final amounts after other payments (those made by programs, organizations, or other plans).
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.
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, 20xx, step therapy will be required for this drug. See
Section 4 for details.
- Drug Removal from Formulary Ex: Effective January 1, 20xx, this drug will be removed from our drug list. See
Section 4 for details.
- Cost-Sharing Tier changes Ex: Effective January 1, 20xx, this drug will be moved from cost-sharing tier 2 to a higher cost-sharing tier (tier 3). See Section 4 for details.
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:
- 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