CMS-10141 Exhibit B: Examples of Section 1 (the List of Prescripti

Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)

Attachment 8c - CY 2020 EOB Exhibit B (version 2)

Medicare Prescription Drug Benefit Program (Plans)

OMB: 0938-0964

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2020 Part D EOB Exhibit B

Exhibit B. Examples that show different versions of Section 1 (the list of prescriptions)

NOTE: The examples in this exhibit have been designed to illustrate some of the main variations in model language for Section 1 of the draft revised Model Part D Explanation of Benefits (EOB). This section shows the list of prescriptions filled by a plan member.

These examples of Section 1 use numbers for the year 2020 and placeholders for the names of drugs. To help show how Section 1 would look in an actual Part D EOB, the examples include fictional information for the rest of the prescription-related text



PART 1. Examples 1-2: variations in text at end of Chart 1 that explain the totals

Examples 1 and 2 are designed to illustrate differences in the wording of the text that explains the total amounts which appear at the bottom of the Chart 1 list of prescriptions. These examples are for plan members who have no supplemental drug coverage. Each is in a different payment stage:

  • Example 1 shows a version of Section 1 for a plan member who is in the deductible payment stage. This member receives no payments from the plan or from third parties.

  • Example 2 shows a version of Section 1 for a plan member who is in the initial coverage period. This member receives payments from the plan, from the Extra Help program (these payments count toward out-of-pocket costs), and from Worker’s Compensation (these payments do not count toward out-of-pocket costs).



[Example 1: Deductible payment stage, no payments from plan or others]

SECTION 1. Your prescriptions during the past month

  • Chart 1 shows your prescriptions for covered Part D drugs for the past month.

  • Please look over this information about your prescriptions to be sure it is correct. If you have any questions or think there is a mistake, Section 5 tells what you should do.

CHART 1.

Your prescriptions for covered Part D drugs

March 2020




Plan paid


You paid

Other payments (made by programs or organizations; see Section 3)

{insert name of first drug} 40 mg tabs

03/09/20, ABC Pharmacy

Rx# 106663421555, 30 day supply

Negotiated Price Change (01/01/2020 to date): $104 increase.

There are lower cost therapeutic alternatives available. Please contact your provider for these options.



$0.00



$45.18



$0.00

{insert name of second drug} 25 mg caps

03/09/20, ABC Pharmacy

Rx# 349000711222, 30 day supply



$0.00



$13.80



$0.00

TOTALS for the month of March 2020:

Your “out-of-pocket costs” amount is $58.98. (This is the amount you paid this month ($58.98) plus the amount of “other payments” made this month that count toward your “out-of-pocket costs” ($0.00). See definitions in Section 3.)

Your “total drug costs” amount is $58.98. (This is the total for this month of all payments made for your drugs by the plan ($0.00) and you ($58.98) plus “other payments” ($0.00).)

$0.00

(total for the month)

$58.98

(total for the month)

$0.00

(total for the month)


Shape1

(continued)




Year-to-date totals

1/1/20 through 3/31/2020

Plan paid


You paid


Other payments (made by programs or organizations; see Section 3)

Your year-to-date amount for “out-of-pocket costs” is $58.98.

Your year-to-date amount for “total drug costs” is $58.98.

For more about “out-of-pocket costs” and “total drug costs,” see Section 3.

$0.00

(year-to-date total)

$58.98

(year-to-date total)

$0.00

(year-to-date total)



[Example 2: Initial coverage stage, payments from plan, from Extra Help, and from another organization]

SECTION 1. Your prescriptions during the past month

  • Chart 1 shows your prescriptions for covered Part D drugs for the past month.

  • Please look over this information about your prescriptions to be sure it is correct. If you have any questions or think there is a mistake, Section 5 tells what you should do.

CHART 1.

Your prescriptions for covered Part D drugs

March 2020




Plan paid


You paid

Other payments (made by programs or organizations; see Section 3)

{insert name of first drug} inj 100 u/ml

03/09/20, ABC Pharmacy

Rx# 124868934511, 15 day supply

Negotiated Price Change (01/01/2020 to date): $104 increase.

There are lower cost therapeutic alternatives available. Please contact your provider for these options.

$107.11

$21.42


$14.28

(paid by “Extra Help”)

{insert name of second drug} 240 mg caps

03/12/20, Springfield Drugs

Rx# 316582122880, 30 day supply

$6.60

$1.32


$2.26

(paid by “Extra Help”)

{insert name of third drug} 150 mg tabs

03/15/20, ABC Pharmacy

Rx# 632005552144, 30 day supply


$326.90


$10.00


$43.59

(paid by “Extra Help”)

$65.38

Shape2

(continued)

(paid by Worker’s Compensation)

{insert name of fourth drug} 50 mg tabs

03/15/20, ABC Pharmacy

Rx# 529042917765, 30 day supply

Negotiated Price Change (01/01/2020 to date): $104 increase.

There are lower cost therapeutic alternatives available. Please contact your provider for these options.

NOTE: Beginning on December 1, 2020, step therapy will be required for this drug. See Section 4 for details.

$60.17

$12.03


$8.02

(paid by “Extra Help”)

{insert name of first drug} 100 u/ml

03/15/20, ABC Pharmacy

Rx# 124868900912, 15 day supply

$107.11

$21.42


$14.28

(paid by “Extra Help”)

TOTALS for the month of March 2020:

Your “out-of-pocket costs” amount is $148.62. (This is the amount you paid this month ($66.19) plus the amount of “other payments” made this month that count toward your “out-of-pocket costs” ($82.43). See definitions in Section 3.)

Your “total drug costs” amount is $821.89. (This is the total for this month of all payments made for your drugs by the plan ($607.89) and you ($66.19) plus “other payments” ($147.81).)


$607.89

(total for the month)


$66.19

(total for the month)


$147.81

(total for the month)

(Of this amount, $82.43 counts toward your “out-of pocket costs. See definitions in Section 3.)




Shape3

(continued)




Year-to-date totals as of 9/30/20

Plan paid


You paid


Other payments (made by programs or organizations; see Section 3)

Your year-to-date amount for “out-of-pocket costs” is $690.80.

Your year-to-date amount for “total drug costs” is $2,136.26.

For more about “out-of-pocket costs” and “total drug costs,” see Section 3.

$1,314.70

(year-to-date total)

$445.20

(year-to-date total)

$376.36

(year-to-date total)

(Of this amount, $245.60 counts toward your “out-of pocket costs.” See definitions in Section 3.)





PART 2. Example 3: Using a separate chart for Supplemental Drug Coverage

Example 3 that follows shows a version of Chart 2, which is used to show prescriptions that are covered under the plan’s Supplemental Drug Coverage. This chart follows Chart 1 (it comes immediately after the summary of year-to-date totals).

Showing a separate chart for prescriptions covered under the plan’s Supplemental Drug Coverage helps reduce potential confusion by emphasizing that payments for these prescriptions do not count toward members’ out-of-pocket costs or total drug costs.

NOTE: When Chart 2 is included in an EOB, the following sentence is added to the first bulleted point in the introductory section of Chart 1: “(Prescriptions for drugs covered by our plan’s Supplemental Drug Coverage are shown separately in Chart 2).”

[Example 3: A separate chart (Chart 2) for prescriptions covered by Supplemental Drug Coverage]


CHART 2.

Your prescriptions for drugs covered by our plan’s Supplemental Drug Coverage

March 2020

  • This chart shows your prescriptions for drugs that are not generally covered by Medicare.

  • These drugs are covered for you under our plan’s Supplemental Drug Coverage.




Plan paid


You paid

Other payments (made by programs or organizations; see Section 3)

{insert name of drug} 0.5 mg

03/01/20, ABC Pharmacy

Rx# 836725300111, 30 day supply

Negotiated Price Change (01/01/2020 to date): $104 increase.

There are lower cost therapeutic alternatives available. Please contact your provider for these options.



$2.80



$5.00



$0.00

Totals for the month of March 2020




$2.80 $5.00 $0.00

These payments do not count toward your “out-of-pocket costs” or your “total drug costs” because they are for drugs that are not generally covered by Medicare. (See definitions in Section 3.)





PART 3. Example 4: Using “notes” on Chart 1 to show changes to the formulary

Example 4 shows how explanatory notes are used in Section 1. These notes can provide members additional information related to a prescription, such as notes that highlight general prices increases for that drug, or when a payment for a drug does not count toward out-of-pocket costs, or the drug is only partially covered because it is a compound drug that includes non-Part D drugs. The plan may also suggest lower-cost alternatives that a member and his/her doctor might consider in this section.

[Example 4: Excerpt from Chart 1 showing notes about changes to the formulary]

SECTION 1. Your prescriptions during the past month

  • Chart 1 shows your prescriptions for covered Part D drugs for the past month.

  • Please look over this information about your prescriptions to be sure it is correct. If you have any questions or think there is a mistake, Section 5 tells what you should do.

CHART 1.

Your prescriptions for covered Part D drugs

March 2020




Plan paid


You paid

Other payments (made by programs or organizations; see Section 3)

{insert name of first drug} 30 mg tabs

03/11/20, ABC Pharmacy

Rx# 222003740005, 30 day supply

Negotiated Price Change (01/01/2020 to date): $104 increase.

There are lower cost therapeutic alternatives available. Please contact your provider for these options.

NOTE: Beginning on December 1, 2020, step therapy will be required for this drug. See Section 4 for details.



$48.29



$16.21



$0.00

{insert name of second drug} 50 mg caps

03/21/20, ABC Pharmacy

Rx# 671142913332, 30 day supply

NOTE: Effective December 1, 2020, this drug will be removed from our drug list. See Section 4 for details.



$72.34



$22.60



$0.00

{insert name of third drug} 0.5 mg

03/25/20, ABC Pharmacy

Rx# 444025344660, 30 day supply

NOTE: Effective December 1, 2020, this drug will be moved from cost-sharing tier 2 to a higher cost-sharing tier (tier 3). See Section 4 for details.



$2.80



$5.00



$0.00


{NOTE: This example shows only the first part of Chart 1. The rest of the chart is not included.}





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