Explanation of Benefits, Sections 5 and 6

Medicare will send you an Explanation of Benefits form if you’ve filled any prescription drugs using its Part D plan. The EOB document is a good way to keep track of your plan expenditures. This, in turn, is a good way to ensure that you’re not paying more than you need pay for access to prescription drugs. Think of the EOB document as a check against possible errors by Medicare and/or your pharmacy. It is not a bill, and requires no action on your part, though it is a good idea to read and understand it.

The Explanation of Benefits document is broken down into six sections. In this article, we’ll explain the information displayed in sections five and six.

Section 5

Section five is very straightforward and will usually be the shortest section on the whole document. It explains what you should do if you find a mistake on your Explanation of Benefits form. For example, if your monthly summary lists drugs you’ve not taken or any other incorrect information, you should first call the Member Services phone number for your particular prescription drug plan. Contact numbers will be listed on the EOB document. If you don’t receive appropriate help using those numbers, you may call Medicare directly at 1-800-633-4227.

Section 6

Section six of your EOB document will usually be a bit longer than section five. It explains your rights under the Medicare Part D prescription drug program. It also features something called the Evidence of Coverage, which is the rulebook for your particular Part D plan. The Evidence of Coverage lists various rules that you must follow in order to obtain your prescription drugs under Part D. You may also see information relating to LIS (low-income subsidy) Riders in this section if you are part of Medicare’s Extra Help program or are receiving other financial assistance in obtaining your prescription drugs.

If you have issues related to Medicare’s coverage or payments for your drugs, you should look in the Evidence of Coverage document in section six of your Explanation of Benefits form. It will list specific instructions for asking Medicare to pay for part of a bill, as well as instructions on how to lodge a complaint or file an appeal.

Finally, section six of your Explanation of Benefits document features information that may help you obtain assistance in paying for your necessary drugs. It details Medicare’s Extra Help program, which is also called the low-income subsidy (or LIS) program. If your annual income falls below a certain threshold, you can either call the phone number listed for your Part D plan or call Medicare directly at 1-800-633-4227. You may also be able to get help from your state’s pharmaceutical assistance program. Some states have organizations called SPAPs (State Pharmaceutical Assistance Programs) that help based on financial needs, age, and medical condition. The contact information for your SPAP will be listed in your Explanation of Benefits section six Evidence of Coverage document.

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