Dream EOBFLOYD R MORSE JR PO BOX 63 SCOTTSVILLE NY 14546-0063
AARP Medicare Advantage Focus (HMO-POS) is operated by UnitedHealthcare or its affiliates
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 1-866-627-7806, TTY: 711.
1-866-627-7806, 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 15, 2021
Hello FLOYD R MORSE JR,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 1-866-627-7806, 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: 95297049600
Plan: AARP Medicare Advantage Focus (HMO-POS)
Go paperless.
MID 952970496 EOB ID 381038276-H1045-045-000 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 $18,038.29 $5,524.01 $4,934.01 $590.00
Totals for 2021 $131,284.47 $24,526.46 $22,609.73 $1,916.73
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 $74.49 $84.75
Totals for 2021 $407.56 $573.67
See Your prescription drug claims received in August 2021 for detailed information about claims received this month.
MID 952970496 EOB ID 381038276-H1045-045-000 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 $3,400.00 out-of-pocket maximum. You have $1,205.45 $2,194.55 of $3,400.00 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 1,700 3,400
MID 952970496 EOB ID 381038276-H1045-045-000 This is not a bill.
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.
Important information about this claim:
Penalty or Interest Payment by Payer•
Provider: MOHAMEDTAKI A TEJANI MD Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 035103999 amount)
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214
You pay a $20.00 copayment for services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/•
• Copayment Amount
$390.00Totals $136.19 $116.19 $20.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 4
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: UNIV OF ROCHESTER/STRONG MEMORIAL HOSP Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 011804274 amount)
June 7, 2021 $462.00 $0.00 $0.00 $0.00
HOSPITAL OUTPATIENT CLIN VISIT ASSESS & MGMT PT
Billing code G0463-95 Denied – look below for information about your appeal rights.•
• Charge exceeds fee schedule/maximum allowable or contracted/
• Copayment Amount
Claim denied
You are NOT responsible for payment: All or part of this claim was denied. However, you are not responsible to pay the
billed amount. We will send you a new EOB or Notice of Denial of Payment letter if there are updates that change what you owe. If you have questions, please call us toll-free at 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Additional contact information (including Medicare) is listed on page 1.
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 5
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: CHRISTOPHER KHAMPHOUNE MD Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 035403948 amount)
New patient outpatient visit, total time 45-59 minutes
Billing code 99204-25 Charge exceeds fee schedule/maximum allowable or contracted/•
June 15, 2021 $8.00 $4.36 $4.36 $0.00
Brief emotional or behavioral assessment
Billing code 96127
$258.00Totals $169.10 $169.10 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 6
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: UNIV ROCHESTER/STRONG/PROF FEES Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035188189 amount)
Physician telephone patient service, 11-20 minutes of medical discussion
Billing code 99442 You pay $20.00 for the services from an Out-of-Network Provider.•
• SERVICES NOT PROVIDED BY NETWORK/PRIMARY CARE PROVIDERS.
• Copayment Amount
$280.00Totals $89.90 $69.90 $20.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 7
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: PRASAD VARMA S PENMETSA MD Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 035254534 amount)
Established patient outpatient visit, total time 20-29 minutes
Billing code 99213 You pay a $20.00 copayment for services from a Network Provider.•
• Charge exceeds fee schedule/maximum allowable or contracted/
• Copayment Amount
$101.00Totals $89.64 $69.64 $20.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 8
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: UNIV OF ROCHESTER/STRONG MEMORIAL HOSP Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 011805564 amount)
Insertion of needle into vein for collection of blood sample
Billing code 36415 Charge exceeds fee schedule/maximum allowable or contracted/•
July 2, 2021 $52.00 $10.56 $10.56 $0.00
Blood test, comprehensive group of blood chemicals
Billing code 80053
Carcinoembryonic antigen (CEA) protein level
Billing code 82378
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 9
Claim #: 011805564 amount)
Magnesium level
Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9
Billing code 86301
Charge exceeds fee schedule/maximum allowable or contracted/•
July 2, 2021 $39.00 $7.77 $7.77 $0.00
Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell
count
Billing code 85025 Charge exceeds fee schedule/maximum allowable or contracted/•
July 2, 2021 $25.00 $4.29 $4.29 $0.00
Blood test, clotting time
$353.00Totals $72.09 $72.09 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 10
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: CHRISTOPHER KHAMPHOUNE MD Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 035381567 amount)
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214-25 Charge exceeds fee schedule/maximum allowable or contracted/•
July 8, 2021 $8.00 $4.36 $4.36 $0.00
Brief emotional or behavioral assessment
Billing code 96127
Urinalysis, manual test
Billing code 81002
$178.00Totals $133.77 $133.77 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 11
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: UNIV OF ROCHESTER/STRONG MEMORIAL HOSP Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 011814616 amount)
Pharmacy-General
Billing code 0250 Denied – look below for information about your appeal rights.•
• The benefit for this service is included in the payment for
July 9, 2021 $60.01 $0.00 $0.00 $0.00
Medical/Surgical Supplies and Devices-Sterile Supply
Billing code 0272
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 9, 2021 $517.50 $0.00 $0.00 $0.00
PORT INDWELLING
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 12
Claim #: 011814616 amount)
Fluoroscopic guidance for insertion, replacement or removal of central venous access device
Billing code 77001-TC
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 9, 2021 $6,390.00 $2,858.23 $2,683.23 $175.00
Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older
Billing code 36561
You pay a $175.00 copayment for services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/•
Copayment Amount•
July 9, 2021 $357.00 $0.00 $0.00 $0.00
Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes
Billing code 99152
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 13
Claim #: 011814616 amount)
Moderate sedation services by physician also performing a procedure, additional 15 minutes
Billing code 99153
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 9, 2021 $1.65 $0.00 $0.00 $0.00
INJECTION CEFAZOLIN SODIUM 500 MG
Billing code J0690
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 9, 2021 $5.00 $0.00 $0.00 $0.00
INJECTION CEFAZOLIN SODIUM 500 MG
Billing code J0690
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 14
Claim #: 011814616 amount)
INJECTION HEPARIN SODIUM PER 10 UNITS
Billing code J1642
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 9, 2021 $1.22 $0.00 $0.00 $0.00
INJECTION MIDAZOLAM HCL PER 1 MG
Billing code J2250
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 9, 2021 $2.85 $0.00 $0.00 $0.00
INJECTION FENTANYL CITRATE 0.1 MG
Billing code J3010
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
$8,031.21Totals $2,858.23 $2,683.23 $175.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 15
Claim denied
You are NOT responsible for payment: All or part of this claim was denied. However, you are not responsible to pay the
billed amount. We will send you a new EOB or Notice of Denial of Payment letter if there are updates that change what you owe. If you have questions, please call us toll-free at 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week. Additional contact information (including Medicare) is listed on page 1.
Important information about this claim:
Penalty or Interest Payment by Payer•
Provider: RADIOLOGISTS/UNIV OF ROCHESTER Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035269390 amount)
July 9, 2021 $1,280.00 $328.07 $328.07 $0.00
Insertion of central venous catheter and implanted device for infusion beneath the skin, patient 5 years or older
Billing code 36561
Fluoroscopic guidance for insertion, replacement or removal of central venous access device
Billing code 77001-26
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 16
Provider: RADIOLOGISTS/UNIV OF ROCHESTER Total cost Provider
Out-of-Network Provider (allowed Plan paid Your share billed plan
Claim #: 035269390 amount)
July 9, 2021 $50.00 $12.25 $12.25 $0.00
Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes
Billing code 99152
$1,400.00Totals $358.63 $358.63 $0.00
Penalty or Interest Payment by Payer•
Provider: UNIV ROCHESTER/STRONG/PROF FEES Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035280822 amount)
Established patient outpatient visit, total time 40-54 minutes
Billing code 99215
$244.00Totals $144.20 $144.20 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 17
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: UNIV OF ROCHESTER/STRONG MEMORIAL HOSP Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 011831270 amount)
Pharmacy-General
Billing code 0250 Denied – look below for information about your appeal rights.•
• The benefit for this service is included in the payment for
July 12, 2021 $5.50 $0.00 $0.00 $0.00
Pharmacy-General
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 12, 2021 $15.76 $0.00 $0.00 $0.00
Pharmacy-General
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 18
Claim #: 011831270 amount)
Pharmacy-General
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 12, 2021 $160.00 $61.90 $0.00 $61.90
Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour
Billing code 96367
You pay a $175.00 copayment for services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/•
Copayment Amount•
Billing code G0463-25
You pay a $175.00 copayment for services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/•
Copayment Amount•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 19
Claim #: 011831270 amount)
Billing code 80053
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 12, 2021 $33.00 $0.00 $0.00 $0.00
Magnesium level
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 12, 2021 $39.00 $0.00 $0.00 $0.00
Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell
count
Billing code 85025 Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 20
Claim #: 011831270 amount)
Infusion of chemotherapy into a vein up to 1 hour
Billing code 96413
Charge exceeds fee schedule/maximum allowable or contracted/•
July 12, 2021 $245.00 $61.90 $61.90 $0.00
Infusion of different chemotherapy drug or substance into a vein up to 1 hour
Billing code 96417
INJECTION PALONOSETRON HCL 25 MCG
Billing code J2469
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 21
Claim #: 011831270 amount)
INJECTION MAGNESIUM SULPHATE PER 500 MG
Billing code J3475
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 12, 2021 $13.33 $0.00 $0.00 $0.00
INJECTION CISPLATIN POWDER OR SOLUTION 10 MG
Billing code J9060
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 12, 2021 $39.75 $0.00 $0.00 $0.00
INJECTION GEMCITABINE HCL NOS 200 MG
Billing code J9201
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 22
Claim #: 011831270 amount)
July 12, 2021 $97.00 $39.95 $39.95 $0.00
Injection of different drug or substance into a vein for therapy, diagnosis, or prevention
Billing code 96375
$1,988.60Totals $592.73 $417.73 $175.00
Claim denied
You are NOT responsible for payment: All or part of this claim was denied. However, you are not responsible to pay the
billed amount. We will send you a new EOB or Notice of Denial of Payment letter if there are updates that change what you owe. If you have questions, please call us toll-free at 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Additional contact information (including Medicare) is listed on page 1.
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 23
Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: HIGHLAND HOSPITAL Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 011831087 amount)
Pharmacy-General
Billing code 0250 Denied – look below for information about your appeal rights.•
• The benefit for this service is included in the payment for
July 19–20, 2021 $14.00 $0.00 $0.00 $0.00
Manual urinalysis test with examination using microscope, automated
Billing code 81001
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $40.00 $0.00 $0.00 $0.00
Blood test, basic group of blood chemicals (Calcium, total)
Billing code 80048
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 24
Provider: HIGHLAND HOSPITAL Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 011831087 amount)
Liver function blood test panel
Billing code 80076
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $32.00 $0.00 $0.00 $0.00
Amylase (enzyme) level
Billing code 82150
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $59.00 $0.00 $0.00 $0.00
Lactic acid level
Billing code 83605
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 25
Provider: HIGHLAND HOSPITAL Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 011831087 amount)
Lipase (fat enzyme) level
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $39.00 $0.00 $0.00 $0.00
Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell
count
Billing code 85025 Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $442.00 $142.63 $52.63 $90.00
NFCT DS RNA 4 TARGETS UPPER RESPIRATORY SPECIMEN
Billing code 0241U
You pay $90.00 for the services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/•
Copayment Amount•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 381038276-H1045-045-000 MID 952970496 This is not a bill.
Material ID Y0066_Combined_EOB_C 26
Provider: HIGHLAND HOSPITAL Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 011831087 amount)
Bacterial blood culture
Billing code 87040
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $50.00 $0.00 $0.00 $0.00
Bacterial blood culture
Billing code 87040-59
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $40.00 $0.00 $0.00 $0.00
Bacterial colony count, urine
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Provider: HIGHLAND HOSPITAL Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 011831087 amount)
Microbial identification
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $35.00 $0.00 $0.00 $0.00
Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral)
Billing code 87184
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 19–20, 2021 $880.00 $231.32 $231.32 $0.00
Emergency department visit, moderately severe problem
Billing code 99283
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Provider: HIGHLAND HOSPITAL Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 011831087 amount)
INJECTION HEPARIN SODIUM PER 10 UNITS
Billing code J1642
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
$1,788.48Totals $373.95 $283.95 $90.00
Claim denied
You are NOT responsible for payment: All or part of this claim was denied. However, you are not responsible to pay the
billed amount. We will send you a new EOB or Notice of Denial of Payment letter if there are updates that change what you owe. If you have questions, please call us toll-free at 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Additional contact information (including Medicare) is listed on page 1.
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: EMERGENCY ASSOCIATES/UNIV ROCH Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035479963 amount)
Billing code 99284 SERVICES NOT PROVIDED BY NETWORK/PRIMARY CARE PROVIDERS.•
$445.00Totals $120.69 $120.69 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: RADIOLOGISTS/UNIV OF ROCHESTER Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035542914 amount)
X-ray of upper arm, minimum of 2 views
Billing code 73060-26,LT SERVICES NOT PROVIDED BY NETWORK/PRIMARY CARE PROVIDERS.•
$35.00Totals $8.18 $8.18 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: RADIOLOGISTS/UNIV OF ROCHESTER Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035542847 amount)
Billing code 73030-26,LT SERVICES NOT PROVIDED BY NETWORK/PRIMARY CARE PROVIDERS.•
July 29, 2021 $35.00 $8.86 $8.86 $0.00
X-ray of shoulder blade
$75.00Totals $18.07 $18.07 $0.00
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: HIGHLAND HOSPITAL Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 011841382 amount)
X-ray of shoulder blade
Billing code 73010-TC,LT Denied – look below for information about your appeal rights.•
• The benefit for this service is included in the payment for
July 29, 2021 $322.00 $0.00 $0.00 $0.00
X-ray of shoulder, minimum of 2 views
Billing code 73030-TC,LT
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
July 29, 2021 $201.00 $0.00 $0.00 $0.00
X-ray of upper arm, minimum of 2 views
Billing code 73060-TC,LT
Denied – look below for information about your appeal rights.•
The benefit for this service is included in the payment for•
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Provider: HIGHLAND HOSPITAL Total cost Provider
Network Provider (allowed Plan paid Your share billed plan
Claim #: 011841382 amount)
Emergency department visit, moderately severe problem
Billing code 99283-25
You pay a $90.00 copayment for services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/•
Copayment Amount•
Claim denied
You are NOT responsible for payment: All or part of this claim was denied. However, you are not responsible to pay the
billed amount. We will send you a new EOB or Notice of Denial of Payment letter if there are updates that change what you owe. If you have questions, please call us toll-free at 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week. Additional contact information (including Medicare) is listed on page 1.
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Important information about this claim:
• Penalty or Interest Payment by Payer
Provider: UNIVERSITY OF ROCHESTER Total cost Provider
Plan paid Your shareOut-of-Network Provider (allowed billed plan
Claim #: 035505510 amount)
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214 SERVICES NOT PROVIDED BY NETWORK/PRIMARY CARE PROVIDERS.•
$405.00Totals $127.32 $127.32 $0.00
Questions? Call toll-free 1-866-627-7806, 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: WALGREENS #10382 Total drug Price Other Plan paid Your share
Rx #: 000000623848 cost change payments
August 5, 2021 $11.96 0% $10.26 $0.00 $1.70
Alprazolam Tab 0.25mg
• Qty filled: 50 (17-day supply) • Drug Tier 1
Pharmacy: WALGREENS #10382 Total drug Price Other Plan paid Your share
Rx #: 000000625739 cost change payments
August 11, 2021 $21.54 0% $0.00 $0.00 $21.54
Diphen/atrop Tab 2.5mg
Drug(s) with a lower cost-share or price: LOPERAMIDE CAP 2MG•
Continued
Questions? Call toll-free 1-866-627-7806, 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
Pharmacy: THE SHERWOOD I DEUTSCH Total drug Price Other Plan paid Your share
PHARMACY cost change payments
Opium Tin 10mg/ml
• Qty filled: 25 (16-day supply) • Drug Tier 4
Pharmacy: WALGREENS #10382 Total drug Price Other Plan paid Your share
Rx #: 000000627018 cost change payments
August 17, 2021 $3.82 0% $0.00 $0.00 $3.82
Ciprofloxacn Tab 500mg
$84.75 N/ATotals $10.26 $0.00 $74.49
Notes related to August totals:
• Your "out-of-pocket costs" amount is $74.49. This is the amount you paid this month ($74.49) 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 $84.75. This is the total for this month of all payments made for your drugs by the plan•
($10.26) and you ($74.49) plus "Other payments" ($0.00).
Continued
Questions? Call toll-free 1-866-627-7806, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
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Notes related to August totals (continued):
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, $74.49 counts toward your out-of-pocket costs.•
Year-to-date totals Total Other Plan paid Your share
January 1, 2021 through August 31, 2021 drug cost payments
$573.67 $166.11 $0.00 $407.56
Your year-to-date amount for “total drug costs” is $573.67.
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, $407.56 counts toward your out-of-pocket costs.•
Questions? Call toll-free 1-866-627-7806, 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 You are in this stage $4,130 $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 less
than 25% of the costs of generic• You generally stay in this stage drugs.until the amount of your
year-to-date "total drug costs" • You generally stay in this stage reaches $4,130. As of until the amount of your
08/31/2021, your year-to-date year-to-date "out-of-pocket
"total drug costs" were $573.67. costs" (see Your out-of-pocket
(See definitions in Section 3.) costs and total drug costs
section) reaches $6,550. When this happens, you move to payment Stage 4, Catastrophic Coverage.
What happens next?
Once you have an additional $3,556.33 in "total drug costs," you move to the next payment stage (Stage 3, Coverage Gap).
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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
$74.49 month of August 2021 $84.75 month of August 2021 $407.56 year-to-date (since January 2021) $573.67 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 1-866-627-7806, 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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