CMS-10141 Exhibit D: Example of Section 3 (Amounts and Definitions

2020 EOB Exhibit D

Exhibit D. Example of Section 3 (amounts and definitions for TrOOP and total drug costs) for a plan that offers Supplemental Drug Coverage

NOTE: The page that follows has a fictional example of Section 3 from the draft revised Model Part D EOB; it is for a fictional plan that offers Supplemental Drug Coverage. Using numbers from 2020 for illustration, this section gives amounts and definitions of out-of-pocket costs and total drug costs.

The main purpose of Section 3 is to give the definitions. The monthly and year-to-date totals for a member’s out-of-pocket costs and total drug costs have already been given at the end of Chart 1 in Section 1 (Section 1 is the list of prescriptions filled during the month).

SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and definitions)

We’re including this Section to help you keep track of your “out-of-pocket costs” and “total drug costs” because these costs determine which drug payment stage you are in. As explained in Section 2, the payment stage you are in determines how much you pay for your prescriptions.

Your “out-of-pocket costs”		Your “total drug costs”
$310.60 month of September, 2020 $4,356.00 year-to-date (since January, 2020) (This total includes $312.50 in out-of-pocket costs from when you were in a different plan earlier this year.)		$453.84 month of September, 2020 $6,244.34 year-to-date (since January, 2020) (This total includes $600.50 in total drug costs from when you were in a different plan earlier this year.)
DEFINITION: “Out of pocket costs” includes: What you pay when you fill or refill a prescription for a covered Part D drug. (This includes payments for your drugs, if any, that are made by family or friends.) Payments made for your drugs by any of the following programs or organizations: “Extra Help” from Medicare, Medicare’s Coverage Gap Discount Program; Indian Health Service; AIDS drug assistance programs; most charities, and most State Pharmaceutical Assistance Programs (SPAPs). It does not include: Payments made for: a) plan premiums, b) drugs not covered by our plan; c) non-Part D drugs (such as drugs you receive during a hospital stay); d) drugs covered by our plan’s Supplemental Drug Coverage; e) 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 Veteran’s Administration; Worker’s Compensation, and some other programs.		DEFINITION: “Total drug costs” is the total of all payments made for your covered Part D drugs. It includes: What the plan pays. What you pay. What others (programs or organizations) pay for your drugs. NOTE: Our plan offers Supplemental Drug Coverage for some drugs not generally covered by Medicare. If you have filled any prescriptions for these drugs this month, they are listed in a separate chart (Chart 2) in Section 1. The amounts paid for these drugs do not count toward your out-of-pocket costs or total drug costs.

Learn more. Medicare has made the rules about which types of payments count and do not count toward “out-of-pocket costs” and “total drug costs.” The definitions on this page give you only the main rules. For details, including more about “covered Part D drugs,” see the Evidence of Coverage, our benefits booklet (for more about the Evidence of Coverage, see Section 6).

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CMS does not discriminate in its programs and activities: To request this form in an accessible format (e.g., Braille, Large Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting your plan, call: 1-800-MEDICARE.

Form CMS-10141 OMB Control No. 0938-0964 (Expires 11/30/2021)