Understanding your explanation of benefits

Learn how to read and use your EOBs with our guides.

An explanation of benefits (EOB) breaks down the costs of services you received — for example, doctor’s visits or lab tests — and shows how much you and your health plan have to pay. An EOB is not a bill.

  • Keep your EOBs and save your receipts. This way, you can cross-check the claims listed on your EOBs with your receipts to make sure everything is correct.

With a Medicare Advantage plan like Sharp Direct Advantage®, there are two kinds of EOBs: Part C for your medical and hospital care and Part D for your prescription drug coverage.

  

Part C Explanation of benefits for medical and hospital care

Your EOB for medical and hospital care shows:

  • Contact information if you have any questions
  • Information about your plan’s yearly spending limit or maximum out-of-pocket (MOOP) amount
  • How much you’ve spent toward your MOOP amount compared to your plan’s MOOP amount
  • Detailed claims information for your services covered through Part A and Part B

You get an EOB each month that your account shows claims activity. See a sample Part C EOB below or view a full PDF.

Page 1 of your EOB

1

Member information
Shows member who received care. All information in the EOB refers to this person.

2

Contact information
Who to contact with questions about your EOB.

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Page 2 - 3 of your EOB

3

Totals for medical and hospital claims
The two middle columns show the total amount your provider billed Sharp Health Plan and the total amount allowed by Sharp Health Plan. The two right columns show the cost-share amounts between your plan (Sharp Health Plan) and you.

4

Yearly limit
Your yearly limit is the most you can pay for covered health care in a 12-month period. This is also called your maximum out-of-pocket or MOOP.

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Page 4 of your EOB

5

Provider and claim number
Your provider that submitted a claim to (asked for payment from) Sharp Health Plan for medical and hospital services you received. Each claim is assigned a claim number.

6

Date of service
Date of your medical or hospital service.

7

Amount the provider billed the plan
How much your health care provider charged for your service.

8

Total cost (amount the plan approved)
How much Sharp Health Plan approved to pay for a covered service with that provider.

9

Plan’s share
How much Sharp Health Plan paid the provider towards each service.

10

Your share
How much you paid or need to pay.

11

Name of service
Description of your medical or hospital service.

12

Billing code
Code for your medical or hospital service.

13

Totals
Total amounts for the services you received from this provider.

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Part D Explanation of benefits for prescription drug coverage

Your EOB for prescription drug coverage shows

  • Contact information if you have any questions
  • Claims processed during the monthly reporting period, including names and costs of drugs
  • Payments made by you, by Sharp Health Plan and by other programs, if applicable
  • Information about your current drug payment stage
  • Any adjustments for the plan year or corrections to your total out-of-pocket costs and total drug costs
  • Important resources related to your coverage and help paying for prescription drugs

You get a Part D EOB by the end of the month, after the month you use your prescription drug coverage. For example, if you fill a prescription in January using your drug plan coverage, you should get an EOB by the end of February. See a sample Part D EOB below or view a full PDF.

Page 1 of your EOB

1

Member information
Shows member who received care. All information in the EOB refers to this person.

2

Contact information
Who to contact with questions about your EOB.

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Section 1 of your EOB

3

Your prescriptions for covered
Part D drugs

Names, Rx numbers and supply amounts of your prescriptions for covered Part D drugs for the past month. Lower-cost therapeutic alternatives and relevant drug list updates, when applicable, are listed here too.

4

Plan paid
How much Sharp Health Plan paid for each prescription drug.

5

You paid
How much you paid.

6

Other payments
Payments made for your drugs by any of the following programs or organizations: Extra Help from Medicare; Medicare’s Coverage Gap Discount Program; Indian Health Service; AIDS drug assistance programs; most charities; and most State Pharmaceutical Assistance Programs.

7

Drug Price & Price Change
The Drug Price shows the cost of each drug. The Price Change shows the percentage of the drug price since it was first filled during the current benefit year.

8

Totals for the past month
Total out-of-pocket and drug costs for the past month as defined by Section 3 of your Part D EOB.

9

Year-to-date totals
Total year-to-date amounts for your out-of-pocket costs and total drug costs as defined by Section 3 of your Part D EOB.

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Section 2 of your EOB

This section shows which drug payment stage you are in: yearly deductible, initial coverage, coverage gap or catastrophic coverage.

10

Drug payment stage
Your drug payment stage. How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it.

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Section 3 of your EOB

This section lists your “out-of-pocket costs” and “total drug costs” for the past month and for the current benefit year. It also shows what payments are included and not included toward each amount.

11

"Out-of-pocket costs”
Your out-of-pocket costs for the month and year-to-date.

12

"Total drug costs”
Your total drug costs for the month and year-to-date.

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Section 4 of your EOB

This section tells you about any updates to the drug list that affect the drugs you take, if any. When an update to the drug list affects a drug you’re taking, this section provides information on options you have, including talking to your doctor about any different covered drugs you can take or requesting an exception.

13

Updates to the plan’s drug list that affect drugs you take
This shows updates to the drug list that change the coverage or cost of drugs you take.

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Sections 5 and 6 of your EOB

These sections of the Part D EOB provide important resources related to your coverage and help paying for prescription drugs.
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Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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Page Last Updated: 3/22/2022
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