NOTE: The amount in the includes payments made for you by Extra Help for Medicare Part D drugs. “plan’s share” column Extra Help is a Medicare program that helps you pay prescription drug costs. [Insert if applicable: The column “plan’s share” also includes payments made for you by <names(s) of other programs or organizations>.] [Plans should include the name of the pharmacy. Plans Date(s) of service Your share Plan’s share may add the location of the pharmacy and other additional The date(s) you got The amount <plan The amount you may pharmacy information (for example: Non-network the drugs name> pays for the need to pay for the pharmacy), if desired.] drugs drugs [Insert name of drug (other than compound) followed [Insert date(s) filled, $[Insert plan share $[Insert member by quantity, strength, and form (for example: 25 mg using mm/dd/yy amount for this drug. liability amount for tabs). Identify compound drugs as such and provide format.] Include any this drug. Use $0.00 quantity.] payments (e.g., if applicable.] Extra Help) made by [Insert prescription number], [insert amount dispensed as other programs or quantity filled and/or (for example: 15 tablets days’ supply organizations. Use or 30 supply).] [Plans may add additional information days’ $0.00 if applicable.] 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.]
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.]
EOBDrugOnly_CY2018.docx