NOTE: The amount in the “plan’s share” column includes payments made for you by Extra Help for Medicare Part D drugs. Extra Help is a Medicare program that helps you pay prescription drug costs. [Insert if applicable: The “plan’s share” column also includes payments made for you by <names(s) of other programs or organizations>.] [Plans should include the name of the pharmacy. Plans may add the location of the pharmacy and other additional pharmacy information (for example: Non-network pharmacy), if desired.] Date(s) of service The date(s) you got the drugs Plan’s share The amount <plan name> pays for the drugs Your share The amount you may need to pay for the drugs [Insert name of drug (other than compound) followed by quantity, strength, and form (for example: 25 mg tabs). Identify compound drugs as such and provide quantity.] [Insert prescription number], [insert amount dispensed as quantity filled and/or days’ supply (for example: 15 tablets or 30 days’ supply).] [Plans may add additional information about the prescription; if preferred, plans may insert drug information here exactly as shown on the pharmacy claim.] [If Section C contains a change that applies to a drug listed in the drug claims chart, plans must insert a note here to alert the member that this change has taken place. For example: Note: Beginning on June 1, 2018, step therapy will be required for this drug. See Section C for details.] [The plan may also suggest lower-cost alternatives that a member and his or her doctor might want to consider in this section.] [Insert date(s) filled, using mm/dd/yy format.] $[Insert plan share amount for this drug. Include any payments (e.g., Extra Help) made by other programs or organizations. Use $0.00 if applicable.] $[Insert member liability amount for this drug. Use $0.00 if applicable.]
decision.” Making an appeal is a formal way of asking us to change our coverage decision. You can make an appeal if we deny a claim in whole or in part. [Plans with cost sharing insert: You can also make an appeal if we approve a claim but you disagree with how much you are paying for the drug.] There are rules for how appeals are handled. These are legal procedures, and the deadlines are important. You can get a fast appeal if your doctor tells us that your health requires a quick decision. If you have questions, or if you need help making an appeal, you can call: <Plan name> Member Services at <toll-free number>. Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. Medicaid at <phone number>. [Plans must revise references of “Medicaid” to use the State-specific name for the program.] [Plans may add contact information for additional resources such as the State Health Insurance Assistance Program (SHIP), ombudsman, etc.] For more information about making an appeal, please see your Member Handbook. Updates to our Drug List that will affect drugs you take [Use this section to provide negative formulary updates that affect drugs the member is taking—that is, any drugs the member got during the current calendar year while a member of the plan. Include updates only if they affect drugs the member is taking and involve negative changes. (Changes to the formulary from one year to the next do not need to be included in the EOB.) If there are no updates, delete this section. If an update is for a negative formulary change that is not a formulary maintenance change, insert: If you are currently taking this drug, this change will not affect your coverage for this drug for the rest of the plan year.] About the Drug List [Plan must insert if it sends a hard copy List of Covered Drugs: <Plan name> sent you a List of Covered Drugs or “Drug List”