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Dream EOB(HMO) is operated by
MR RAND H KANE UnitedHealthcare or its affiliates 313 COUNTRY VIEW DR IRWIN PA 15642-5715
AARP MedicarePlans P.O. Box 30770
Salt Lake City, UT 84130-0770
This is not a bill.
It is simply a statement of the medical services you received and details on how you and your plan will share costs. It is called an Explanation of Benefits (EOB). The EOB is generated when your provider (or pharmacy, if applicable) submits a claim for services you received.
Do not use this to pay any outstanding bill.
The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.
We provide free services to help you communicate with us, such as letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card.
ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1-800-643-4845, TTY: 711.
1-800-643-4845, TTY: 711.
CEEB TOOM: Yog koj hais Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev mauj nyob rau ntawm koj daim yuaj cim qhia tus kheej.
Your August 2021 Explanation of Benefits September 16, 2021
Hello RAND H KANE,This is not a bill.
If you owe anything, your provider will send you a bill. Inside you'll find a summary of claims for August. It shows what the plan paid and how much you've paid (or will be billed by your provider). It's called your Explanation of Benefits (EOB).What’s inside?
Questions? We’re here to help. Your current cost summary Call if you have questions about claims or benefits, finding providers
near you, suspicious claims or billing, information in this document, or Your out-of-pocket costs issues about your plan.
Call us toll-free at 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local Your medical and hospital claims processed time, 7 days a week. Or visit www.myAARPMedicare.com.
You can also report suspicious or dishonest billing to Medicare at Your prescription drug claims received 1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call
1-877-486-2048). Have questions or think there’s been a mistake?
Your plan information
Part D (prescription drugs) member ID: 90045654700
Plan: AARP Medicare Advantage Plan 1 (HMO)
Go paperless.
MID 900456547 EOB ID 378357321-H1944-010-000 This is not a bill.
Material ID Y0066_Combined_EOB_C 1
Your medical and hospital cost summary This chart is a summary of claims processed in August 2021 and total year to date. Your share includes amounts paid
toward your copays, coinsurance, and deductible. Your share may also include costs that don’t count toward your out-of-pocket maximum, such as denied claims or services. If you owe anything, your provider will send you a bill.
Total cost (allowed Providers billed plan Plan paid Your share
amount)
Totals for August $6,613.68 $1,357.86 $1,137.86 $220.00
Totals for 2021 $21,657.87 $4,592.27 $3,557.47 $1,034.80
See Your medical and hospital claims processed in August 2021 for specific claim details.
Your prescription drug cost summary
This chart is a summary of claims received in August 2021 and total year to date.
Out-of-pocket cost Total drug cost
Totals for August $37.08 $268.01
Totals for 2021 $1,115.28 $4,278.33
See Your prescription drug claims received in August 2021 for detailed information about claims received this month.
MID 900456547 EOB ID 378357321-H1944-010-000 This is not a bill.
Material ID Y0066_Combined_EOB_C 2
Your annual medical and hospital out-of-pocket costs Your out-of-pocket costs (copayments, coinsurance and deductible) show the most money you will have to pay for covered services in a plan year (based on date of service). Some items and services will not count toward that maximum (see your Evidence of Coverage (EOC) to learn more). The amounts listed may include claims in-process and claims paid as of the date noted on page 1 of this EOB. The amounts could change depending on when claims are paid and/or adjusted.
2021 In-Network Annual Out-of-Pocket Maximum
Your plan has a $6,700.00 out-of-pocket maximum. You have $5,565.20 $1,134.80 of $6,700.00 paid
left to pay for covered services for this plan year. The plan pays 100% of the costs after you meet your out-of-pocket maximum.
0 3,350 6,700
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Material ID Y0066_Combined_EOB_C 3
Your medical and hospital claims processed in August 2021
This chart shows your medical and hospital claims processed in August.
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 014688565 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
• MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.
July 6, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$708.71Totals $127.14 $107.14 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 4
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015041533 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
July 9, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ
$708.71Totals $127.14 $107.14 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 5
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015041540 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
July 12, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ
$708.71Totals $127.14 $107.14 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 6
Provider: QUEST DIAGNOSTICS VENTURES LLC Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015466950 amount)
Blood test, clotting time
Billing code 85610
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$39.00Totals $3.51 $3.51 $0.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015675768 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ You pay a $20.00 copayment for services from a Network Provider.•
• MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 7
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015675768 amount)
July 15, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ
$708.71Totals $127.14 $107.14 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015675770 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$559.80Totals $108.09 $88.09 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 8
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016526653 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016388445 amount)
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$215.00Totals $127.03 $127.03 $0.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 9
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016504693 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016750249 amount)
Established patient outpatient visit, total time 20-29 minutes
Billing code 99213
You pay a $40.00 copayment for services from a Network Provider.•
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$261.00Totals $89.42 $49.42 $40.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 10
Provider: JAMES S COSTLOW MD Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016785247 amount)
Insertion of needle into vein for collection of blood sample
Billing code 36415
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$7.00Totals $3.00 $3.00 $0.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016786598 amount)
Blood test, clotting time
Billing code 85610
• WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$10.00Totals $4.29 $4.29 $0.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 11
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016867842 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 017329933 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 12
Your prescription drug claims received in August 2021
This chart shows your claims for covered drugs received in August. Total drug cost is the cost of each drug (including what you or the plan paid). Price change shows the increase or decrease in the drug price since it was first filled during the plan year. Plan paid includes payments from your Part D plan.
There may be drugs with a lower cost-share or price listed below your current drug. Talk with your prescriber to see if an alternative is right for you.
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000292781305 cost change payments
August 12, 2021 $2.10 -34.57% $1.57 $0.00 $0.53
Atorvastatin Tab 10mg
• Qty filled: 90 (90-day supply) • Drug Tier 1
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000299297616 cost change payments
August 12, 2021 $171.75 -25.73% $157.70 $0.00 $14.05
Carb/levo Tab 25-250mg
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 13
Your prescription drug claims received in August 2021
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000309637280 cost change payments
August 12, 2021 $2.51 1.62% $2.51 $0.00 $0.00
Lisinopril Tab 20mg
• Qty filled: 90 (90-day supply) • Drug Tier 1
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000309637281 cost change payments
August 12, 2021 $10.57 13.05% $7.93 $0.00 $2.64
Hydrochlorot Cap 12.5mg
• Qty filled: 90 (90-day supply) • Drug Tier 1
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000309768281 cost change payments
August 12, 2021 $1.63 1.88% $1.63 $0.00 $0.00
Amlodipine Tab 5mg
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 14
Your prescription drug claims received in August 2021
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000315298040 cost change payments
August 12, 2021 $79.45 0% $59.59 $0.00 $19.86
Gabapentin Cap 100mg
$268.01 N/ATotals $230.93 $0.00 $37.08
Notes related to August totals:
• Your "out-of-pocket costs" amount is $37.08. This is the amount you paid this month ($37.08) plus the amount of "Other
payments" made this month that count toward your "out-of-pocket" costs ($0.00). See definitions in the Your out-of-pocket costs
and total drug costs section.
Your "total drug costs" amount is $268.01. This is the total for this month of all payments made for your drugs by the plan•
($230.93) and you ($37.08) plus "Other payments" ($0.00). Of the amount for Other payments, $0.00 counts toward your out-of-pocket costs. See definitions in Your out-of-pocket costs•
and total drug costs section. Of the amount for Your share, $37.08 counts toward your out-of-pocket costs.•
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 15
January 1, 2021 through August 31, 2021 drug cost payments
$4,278.33 $3,163.05 $0.00 $1,115.28
Your year-to-date amount for “total drug costs” is $4,278.33.
For more about “out-of-pocket costs" and “total drug costs,” see Your out-of-pocket costs and total drug costs section.
Notes related to year-to-date totals:
Of the amount for Other payments, $0.00 counts toward your out-of-pocket costs.•
Of the amount for Your share, $1,115.28 counts toward your out-of-pocket costs.•
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Your drug payment stage Your Part D prescription drug coverage has drug payment stages. The amount you pay for covered prescriptions depends on which payment stage you are in when you fill it. Whether you move from one payment stage to the next depends on how much is spent for your drugs during the plan year.
$0 $4,130 You are in this stage $6,550
Stage 1: Yearly Deductible Stage 2: Initial Coverage Stage 3: Coverage Gap Stage 4: Catastrophic Coverage
• (Because there is no deductible • You begin in this payment stage • During this payment stage, you • During this payment stage, the for the plan, this payment stage when you fill your first (or others on your behalf) receive plan pays most of the cost for does not apply to you.) prescription of the year. During a 70% manufacturer’s discount your covered drugs.
this payment stage, the plan on covered brand name drugs • You generally stay in this stage pays its share of the cost of your and the plan will cover another for the rest of the calendar year drugs and you (or others on your 5%, so you will pay 25% of the (through December 31, 2021). behalf) pay your share of the negotiated price on brand-name cost. drugs. In addition, you pay 25%
of the costs of generic drugs.• You generally stay in this stage until the amount of your • You generally stay in this stage year-to-date "total drug costs" until the amount of your
reaches $4,130. Then you year-to-date "out-of-pocket
move to payment Stage 3, costs" reaches $6,550. As of Coverage Gap. 08/31/2021, your year-to-date
"out-of-pocket costs" were $1,115.28. (See Your out-of-pocket costs and total drug costs section.)
What happens next?
Once you (or others on your behalf) have paid an additional $5,434.72 in "out-of-pocket costs," you move to the next payment stage (Stage 4, Catastrophic Coverage).
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Your out-of-pocket costs and total drug costs This section can help you keep track of your out-of-pocket costs and total drug costs to determine which drug payment stage you are in. The drug payment stage you are in determines how much you pay for your prescriptions.
Your out-of-pocket costs Your total drug costs
$37.08 month of August 2021 $268.01 month of August 2021 $1,115.28 year-to-date (since January 2021) $4,278.33 year-to-date (since January 2021)
Out-of-pocket costs includes: Total drug cost is the total of all payments made for your covered
• What you pay when you fill or refill a prescription for a covered Part Part D drugs. It includes:
D drug. (This includes payments for your drugs, if any, that are made • What the plan pays by family or friends.) • What you pay
• Payments made for your drugs by any of the following programs or • What others (programs or organizations) pay for your drugs organizations: Extra Help from Medicare; Medicare’s Coverage Gap
Learn more Discount Program; Indian Health Service; AIDS drug assistance
Medicare has made the rules about which types of payments count programs; most charities; and most State Pharmaceutical
and do not count toward out-of-pocket costs and total drug Assistance Programs (SPAPs).
costs. The explanations on this page give you only the main rules. It does not include:
For details, including more about covered Part D drugs, see the • Payments made for: a) plan premiums, b) drugs not covered by our
Evidence of Coverage (EOC), our benefits booklet (for more about plan, c) non-Part D drugs (such as drugs you receive during a
the EOC, see Section 6). hospital stay), d) drugs obtained at a non-network pharmacy that does not meet our out-of-network pharmacy access policy.
• Payments made for your drugs by any of the following programs or organizations: employer or union health plans; some government-funded programs, including TRICARE and the Veteran’s Administration; Worker’s Compensation; and some other programs.
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Material ID Y0066_Combined_EOB_C 18
Important things to know about your drug coverage and rights
Your Evidence of Coverage (EOC) has the details about your drug coverage and costs.
• The EOC is our plan's benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage.
• You can view the Evidence of Coverage online or call us (our phone number and website are on the cover of this summary) to have a hard copy sent to you.
What if you have problems related to coverage or payments for your drugs?
• Your Evidence of Coverage has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for: – Chapter 7 – Asking the plan to pay its share of a bill you have received for covered services or drugs. – Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Here are things to keep in mind:
• When we decide whether a drug is covered and how much you pay, it's called a "coverage decision." If you disagree with our coverage decision, you can appeal our decision (see Chapter 9 of the EOC).
• Medicare has set the rules for how coverage decisions and appeals are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.
Continued
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Important things to know about your drug coverage and rights
Did you know there are programs to help people pay for their drugs?
• Extra Help from Medicare. You may be able to get Extra Help to pay for your prescription drug premiums and costs. This program is also called the "low-income subsidy" or LIS. People whose yearly income and resources are below certain limits can qualify for this help. To see if you qualify for getting Extra Help, see Section 7 of your Medicare & You 2021 handbook or call 1-800-633-4227 for free, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778. You can also call your State Medicaid Office.
• Help from your State's Pharmaceutical Assistance Program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your EOC.
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Have questions or think there’s been a mistake?
Part C (medical and hospital): Part D (prescription drugs):
• If you have questions about a claim or think there • If you have questions, contact us: If something is confusing or doesn’t look right on this report, please callmight be a mistake, start by calling your provider. us. Or, you can write to us at AARP MedicarePlans, P.O.• If you still have questions, you can also contact us. We Box 30770, Salt Lake City, UT 84130-0770.can help with questions about:
• You can call your State Health Insurance Assistance– Claims or benefits Program (SHIP). The name and phone numbers for this– Finding providers near you organization are in Chapter 2, Section 3 of your Evidence– Suspicious claims or billing of Coverage.– Information in this document
• What about possible fraud? Most health care– Any issues about your plan professionals and organizations that provide Medicare• You have the right to make an appeal or complaint, services are honest. Unfortunately, there may be somewhich is a formal way to ask us to change our coverage who are dishonest. If the monthly summary shows drugsdecision. You can also make an appeal if we deny a claim or you’re not taking or anything else that looks suspicious,if we approve a claim but you disagree with how much you please contact us.are paying for the item or services. Contact us for more
information.
Learn more atToll-free 1-800-643-4845, TTY/RTT 711, www.myAARPMedicare.com8 a.m. - 8 p.m. local time, 7 days a week
You can report suspicious or dishonest billing to Member Services at the number above or Medicare at 1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call 1-877-486-2048).
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MR RAND H KANE UnitedHealthcare or its affiliates 313 COUNTRY VIEW DR IRWIN PA 15642-5715
AARP MedicarePlans P.O. Box 30770
Salt Lake City, UT 84130-0770
This is not a bill.
It is simply a statement of the medical services you received and details on how you and your plan will share costs. It is called an Explanation of Benefits (EOB). The EOB is generated when your provider (or pharmacy, if applicable) submits a claim for services you received.
Do not use this to pay any outstanding bill.
The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.
We provide free services to help you communicate with us, such as letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card.
ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1-800-643-4845, TTY: 711.
1-800-643-4845, TTY: 711.
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Your August 2021 Explanation of Benefits September 16, 2021
Hello RAND H KANE,This is not a bill.
If you owe anything, your provider will send you a bill. Inside you'll find a summary of claims for August. It shows what the plan paid and how much you've paid (or will be billed by your provider). It's called your Explanation of Benefits (EOB).What’s inside?
Questions? We’re here to help. Your current cost summary Call if you have questions about claims or benefits, finding providers
near you, suspicious claims or billing, information in this document, or Your out-of-pocket costs issues about your plan.
Call us toll-free at 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local Your medical and hospital claims processed time, 7 days a week. Or visit www.myAARPMedicare.com.
You can also report suspicious or dishonest billing to Medicare at Your prescription drug claims received 1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call
1-877-486-2048). Have questions or think there’s been a mistake?
Your plan information
Part D (prescription drugs) member ID: 90045654700
Plan: AARP Medicare Advantage Plan 1 (HMO)
Go paperless.
MID 900456547 EOB ID 378357321-H1944-010-000 This is not a bill.
Material ID Y0066_Combined_EOB_C 1
Your medical and hospital cost summary This chart is a summary of claims processed in August 2021 and total year to date. Your share includes amounts paid
toward your copays, coinsurance, and deductible. Your share may also include costs that don’t count toward your out-of-pocket maximum, such as denied claims or services. If you owe anything, your provider will send you a bill.
Total cost (allowed Providers billed plan Plan paid Your share
amount)
Totals for August $6,613.68 $1,357.86 $1,137.86 $220.00
Totals for 2021 $21,657.87 $4,592.27 $3,557.47 $1,034.80
See Your medical and hospital claims processed in August 2021 for specific claim details.
Your prescription drug cost summary
This chart is a summary of claims received in August 2021 and total year to date.
Out-of-pocket cost Total drug cost
Totals for August $37.08 $268.01
Totals for 2021 $1,115.28 $4,278.33
See Your prescription drug claims received in August 2021 for detailed information about claims received this month.
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Material ID Y0066_Combined_EOB_C 2
Your annual medical and hospital out-of-pocket costs Your out-of-pocket costs (copayments, coinsurance and deductible) show the most money you will have to pay for covered services in a plan year (based on date of service). Some items and services will not count toward that maximum (see your Evidence of Coverage (EOC) to learn more). The amounts listed may include claims in-process and claims paid as of the date noted on page 1 of this EOB. The amounts could change depending on when claims are paid and/or adjusted.
2021 In-Network Annual Out-of-Pocket Maximum
Your plan has a $6,700.00 out-of-pocket maximum. You have $5,565.20 $1,134.80 of $6,700.00 paid
left to pay for covered services for this plan year. The plan pays 100% of the costs after you meet your out-of-pocket maximum.
0 3,350 6,700
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Material ID Y0066_Combined_EOB_C 3
Your medical and hospital claims processed in August 2021
This chart shows your medical and hospital claims processed in August.
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 014688565 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
• MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.
July 6, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$708.71Totals $127.14 $107.14 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 4
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015041533 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
July 9, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ
$708.71Totals $127.14 $107.14 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 5
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015041540 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
July 12, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ
$708.71Totals $127.14 $107.14 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 378357321-H1944-010-000 MID 900456547 This is not a bill.
Material ID Y0066_Combined_EOB_C 6
Provider: QUEST DIAGNOSTICS VENTURES LLC Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015466950 amount)
Blood test, clotting time
Billing code 85610
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$39.00Totals $3.51 $3.51 $0.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015675768 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ You pay a $20.00 copayment for services from a Network Provider.•
• MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 7
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015675768 amount)
July 15, 2021 $148.91 $19.05 $19.05 $0.00
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
Billing code 97140-GP,CQ
$708.71Totals $127.14 $107.14 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 015675770 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$559.80Totals $108.09 $88.09 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 8
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016526653 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016388445 amount)
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$215.00Totals $127.03 $127.03 $0.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 9
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016504693 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016750249 amount)
Established patient outpatient visit, total time 20-29 minutes
Billing code 99213
You pay a $40.00 copayment for services from a Network Provider.•
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$261.00Totals $89.42 $49.42 $40.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 10
Provider: JAMES S COSTLOW MD Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016785247 amount)
Insertion of needle into vein for collection of blood sample
Billing code 36415
WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A•
COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$7.00Totals $3.00 $3.00 $0.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016786598 amount)
Blood test, clotting time
Billing code 85610
• WE HAVE PAID THE ALLOWED AMOUNT. YOU SHOULD NOT BE BILLED FOR THE BALANCE, BUT YOU MAY NEED TO PAY A COPAYMENT, COINSURANCE, OR DEDUCTIBLE.
$10.00Totals $4.29 $4.29 $0.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 11
Provider: COREY DAILEY PT Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 016867842 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Network Provider (allowed Plan paid Your share billed plan
Claim #: 017329933 amount)
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
Billing code 97110-GP,CQ
You pay a $20.00 copayment for services from a Network Provider.•
MULTIPLE OR CONCURRENT PROCEDURE RULES. DON'T BILL MEMBER.•
$671.76Totals $128.49 $108.49 $20.00
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Your prescription drug claims received in August 2021
This chart shows your claims for covered drugs received in August. Total drug cost is the cost of each drug (including what you or the plan paid). Price change shows the increase or decrease in the drug price since it was first filled during the plan year. Plan paid includes payments from your Part D plan.
There may be drugs with a lower cost-share or price listed below your current drug. Talk with your prescriber to see if an alternative is right for you.
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000292781305 cost change payments
August 12, 2021 $2.10 -34.57% $1.57 $0.00 $0.53
Atorvastatin Tab 10mg
• Qty filled: 90 (90-day supply) • Drug Tier 1
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000299297616 cost change payments
August 12, 2021 $171.75 -25.73% $157.70 $0.00 $14.05
Carb/levo Tab 25-250mg
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 13
Your prescription drug claims received in August 2021
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000309637280 cost change payments
August 12, 2021 $2.51 1.62% $2.51 $0.00 $0.00
Lisinopril Tab 20mg
• Qty filled: 90 (90-day supply) • Drug Tier 1
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000309637281 cost change payments
August 12, 2021 $10.57 13.05% $7.93 $0.00 $2.64
Hydrochlorot Cap 12.5mg
• Qty filled: 90 (90-day supply) • Drug Tier 1
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000309768281 cost change payments
August 12, 2021 $1.63 1.88% $1.63 $0.00 $0.00
Amlodipine Tab 5mg
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 14
Your prescription drug claims received in August 2021
Pharmacy: OPTUMRX PHARMACY 700, LLC Total drug Price Other Plan paid Your share
Rx #: 000315298040 cost change payments
August 12, 2021 $79.45 0% $59.59 $0.00 $19.86
Gabapentin Cap 100mg
$268.01 N/ATotals $230.93 $0.00 $37.08
Notes related to August totals:
• Your "out-of-pocket costs" amount is $37.08. This is the amount you paid this month ($37.08) plus the amount of "Other
payments" made this month that count toward your "out-of-pocket" costs ($0.00). See definitions in the Your out-of-pocket costs
and total drug costs section.
Your "total drug costs" amount is $268.01. This is the total for this month of all payments made for your drugs by the plan•
($230.93) and you ($37.08) plus "Other payments" ($0.00). Of the amount for Other payments, $0.00 counts toward your out-of-pocket costs. See definitions in Your out-of-pocket costs•
and total drug costs section. Of the amount for Your share, $37.08 counts toward your out-of-pocket costs.•
Continued
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Material ID Y0066_Combined_EOB_C 15
January 1, 2021 through August 31, 2021 drug cost payments
$4,278.33 $3,163.05 $0.00 $1,115.28
Your year-to-date amount for “total drug costs” is $4,278.33.
For more about “out-of-pocket costs" and “total drug costs,” see Your out-of-pocket costs and total drug costs section.
Notes related to year-to-date totals:
Of the amount for Other payments, $0.00 counts toward your out-of-pocket costs.•
Of the amount for Your share, $1,115.28 counts toward your out-of-pocket costs.•
Questions? Call toll-free 1-800-643-4845, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Your drug payment stage Your Part D prescription drug coverage has drug payment stages. The amount you pay for covered prescriptions depends on which payment stage you are in when you fill it. Whether you move from one payment stage to the next depends on how much is spent for your drugs during the plan year.
$0 $4,130 You are in this stage $6,550
Stage 1: Yearly Deductible Stage 2: Initial Coverage Stage 3: Coverage Gap Stage 4: Catastrophic Coverage
• (Because there is no deductible • You begin in this payment stage • During this payment stage, you • During this payment stage, the for the plan, this payment stage when you fill your first (or others on your behalf) receive plan pays most of the cost for does not apply to you.) prescription of the year. During a 70% manufacturer’s discount your covered drugs.
this payment stage, the plan on covered brand name drugs • You generally stay in this stage pays its share of the cost of your and the plan will cover another for the rest of the calendar year drugs and you (or others on your 5%, so you will pay 25% of the (through December 31, 2021). behalf) pay your share of the negotiated price on brand-name cost. drugs. In addition, you pay 25%
of the costs of generic drugs.• You generally stay in this stage until the amount of your • You generally stay in this stage year-to-date "total drug costs" until the amount of your
reaches $4,130. Then you year-to-date "out-of-pocket
move to payment Stage 3, costs" reaches $6,550. As of Coverage Gap. 08/31/2021, your year-to-date
"out-of-pocket costs" were $1,115.28. (See Your out-of-pocket costs and total drug costs section.)
What happens next?
Once you (or others on your behalf) have paid an additional $5,434.72 in "out-of-pocket costs," you move to the next payment stage (Stage 4, Catastrophic Coverage).
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Your out-of-pocket costs and total drug costs This section can help you keep track of your out-of-pocket costs and total drug costs to determine which drug payment stage you are in. The drug payment stage you are in determines how much you pay for your prescriptions.
Your out-of-pocket costs Your total drug costs
$37.08 month of August 2021 $268.01 month of August 2021 $1,115.28 year-to-date (since January 2021) $4,278.33 year-to-date (since January 2021)
Out-of-pocket costs includes: Total drug cost is the total of all payments made for your covered
• What you pay when you fill or refill a prescription for a covered Part Part D drugs. It includes:
D drug. (This includes payments for your drugs, if any, that are made • What the plan pays by family or friends.) • What you pay
• Payments made for your drugs by any of the following programs or • What others (programs or organizations) pay for your drugs organizations: Extra Help from Medicare; Medicare’s Coverage Gap
Learn more Discount Program; Indian Health Service; AIDS drug assistance
Medicare has made the rules about which types of payments count programs; most charities; and most State Pharmaceutical
and do not count toward out-of-pocket costs and total drug Assistance Programs (SPAPs).
costs. The explanations on this page give you only the main rules. It does not include:
For details, including more about covered Part D drugs, see the • Payments made for: a) plan premiums, b) drugs not covered by our
Evidence of Coverage (EOC), our benefits booklet (for more about plan, c) non-Part D drugs (such as drugs you receive during a
the EOC, see Section 6). hospital stay), d) drugs obtained at a non-network pharmacy that does not meet our out-of-network pharmacy access policy.
• Payments made for your drugs by any of the following programs or organizations: employer or union health plans; some government-funded programs, including TRICARE and the Veteran’s Administration; Worker’s Compensation; and some other programs.
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Important things to know about your drug coverage and rights
Your Evidence of Coverage (EOC) has the details about your drug coverage and costs.
• The EOC is our plan's benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage.
• You can view the Evidence of Coverage online or call us (our phone number and website are on the cover of this summary) to have a hard copy sent to you.
What if you have problems related to coverage or payments for your drugs?
• Your Evidence of Coverage has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for: – Chapter 7 – Asking the plan to pay its share of a bill you have received for covered services or drugs. – Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Here are things to keep in mind:
• When we decide whether a drug is covered and how much you pay, it's called a "coverage decision." If you disagree with our coverage decision, you can appeal our decision (see Chapter 9 of the EOC).
• Medicare has set the rules for how coverage decisions and appeals are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.
Continued
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Important things to know about your drug coverage and rights
Did you know there are programs to help people pay for their drugs?
• Extra Help from Medicare. You may be able to get Extra Help to pay for your prescription drug premiums and costs. This program is also called the "low-income subsidy" or LIS. People whose yearly income and resources are below certain limits can qualify for this help. To see if you qualify for getting Extra Help, see Section 7 of your Medicare & You 2021 handbook or call 1-800-633-4227 for free, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778. You can also call your State Medicaid Office.
• Help from your State's Pharmaceutical Assistance Program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your EOC.
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Have questions or think there’s been a mistake?
Part C (medical and hospital): Part D (prescription drugs):
• If you have questions about a claim or think there • If you have questions, contact us: If something is confusing or doesn’t look right on this report, please callmight be a mistake, start by calling your provider. us. Or, you can write to us at AARP MedicarePlans, P.O.• If you still have questions, you can also contact us. We Box 30770, Salt Lake City, UT 84130-0770.can help with questions about:
• You can call your State Health Insurance Assistance– Claims or benefits Program (SHIP). The name and phone numbers for this– Finding providers near you organization are in Chapter 2, Section 3 of your Evidence– Suspicious claims or billing of Coverage.– Information in this document
• What about possible fraud? Most health care– Any issues about your plan professionals and organizations that provide Medicare• You have the right to make an appeal or complaint, services are honest. Unfortunately, there may be somewhich is a formal way to ask us to change our coverage who are dishonest. If the monthly summary shows drugsdecision. You can also make an appeal if we deny a claim or you’re not taking or anything else that looks suspicious,if we approve a claim but you disagree with how much you please contact us.are paying for the item or services. Contact us for more
information.
Learn more atToll-free 1-800-643-4845, TTY/RTT 711, www.myAARPMedicare.com8 a.m. - 8 p.m. local time, 7 days a week
You can report suspicious or dishonest billing to Member Services at the number above or Medicare at 1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call 1-877-486-2048).
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