Explanation of Benefits (EOB)

1. List the item(s) or service(s) for which payment was made and the amount of the payment for each item or service.
2. Include a notice of the enrollee's right to request an itemized statement, appeal/grievance rights, and exceptions process.
3. Include the cumulative, year-to-date total amount of benefits provided, in relation to:
   a. The deductible for the current year.
   b. The initial coverage limit for the current year. (If a Plan provides coverage between the initial coverage limit (ICL) and catastrophic coverage threshold (CCT), plans should give the amount the beneficiary must spend before reaching the CCT).
   c. Total Out-of-Pocket Expenditure (TrOOP).
4. Include the cumulative, year-to-date total of incurred costs to the extent practicable.
5. Include any applicable formulary changes that the Plan is required to provide notice.

NOTE: All year-to-date total amounts mentioned above in (b) and (c) should not include amounts paid by the member's current or former employer/union or another insurance plan or policy.