<Plan name> Explanation of Benefits A summary of your health care [plans may add the following phrase, if preferred: , long-term services and supports,] and drug claims for [insert month and year or date range] [Insert mailing date] Disclaimers For <member name> [Plans that charge $0 copays for all Part D drugs may delete this paragraph.] Copays for prescription drugs may vary based [Plans may also insert a mailing address, member ID member’s on the level of Extra Help you get. Extra Help is a Medicare number, and/or other information typically used in member program that helps you pay prescription drug costs. Please communications. Do not use complete HICN.] contact the plan for more details. This is not a bill. Limitations [, copays,] and restrictions may apply. For more information, call <plan name> Member Services or read the [Insert legal or marketing name] is a health plan that plan’s <plan name> Member Handbook. contracts with both Medicare and [insert name of <State> Medicaid program] to provide benefits of both programs to The Drug List and/or pharmacy and provider networks may enrollees. change throughout the year. We will send you a notice before we make a change that affects you. This Explanation of Benefits (EOB) is a summary of claims (bills) sent to <plan name> for services and drugs you got Benefits [and/or copays] may change on January 1 of each during [insert month and year or date range]. The EOB tells year. [Plans that do not renew on January 1, revise date as you what we paid providers, such as doctors and pharmacies. needed.] [Plans with no cost sharing for all services and drugs, delete the rest of this paragraph.] The EOB also shows how much you paid (or can expect to be billed). If you owe anything, your doctors and other health care providers will send you a bill. Other formats
<Plan name> Explanation of Benefits A summary of your health care [plans may add the following phrase, if preferred: , long-term services and supports,] and drug claims for [insert month and year or date range] [Insert mailing date] For <member name> [Plans may also insert a member’s mailing address, member ID number, and/or other information typically used in member communications. Do not use complete HICN.] This is not a bill. [Insert plan’s legal or marketing name] is a health plan that contracts with both Medicare and [insert name of <State> Medicaid program] to provide benefits of both programs to enrollees. This Explanation of Benefits (EOB) is a summary of claims (bills) sent to <plan name> for services and drugs you got during [insert month and year or date range]. The EOB tells you what we paid providers, such as doctors and pharmacies. [Plans with no cost sharing for all services and drugs, delete the rest of this paragraph.] The EOB also shows how much you paid (or can expect to be billed). If you owe anything, your doctors and other health care providers will send you a bill. Disclaimers [Plans that charge $0 copays for all Part D drugs may delete this paragraph.] Copays for prescription drugs may vary based on the level of Extra Help you get. Extra Help is a Medicare program that helps you pay prescription drug costs. Please contact the plan for more details. Limitations [, copays,] and restrictions may apply. For more information, call <plan name> Member Services or read the <plan name> Member Handbook. The Drug List and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits [and/or copays] may change on January 1 of each year. [Plans that do not renew on January 1, revise date as needed.] Other formats
EOBIntegrated_CY2018.docx