Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

[MA-PD HMO (and HMO-POS, I-SNPs, C-SNPs) models]
[2021 ANOC model]

[Insert 2021 plan name] ([insert plan type]) offered by [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document]

Annual Notice of Changes for 2021

[Optional: insert member name]
[Optional: insert member address]

You are currently enrolled as a member of [insert 2020 plan name]. Next year, there will be some changes to the plan’s costs and benefits. This booklet tells about the changes.

• You have from October 15 until December 7 to make changes to your Medicare coverage for next year.

What to do now

1. ASK: Which changes apply to you

• Check the changes to our benefits and costs to see if they affect you.

• It’s important to review your coverage now to make sure it will meet your needs next year.

• Do the changes affect the services you use?

• Look in Sections [insert section number] and [insert section number] for information about benefit and cost changes for our plan.

• Check the changes in the booklet to our prescription drug coverage to see if they affect you.

• Will your drugs be covered?

• Are your drugs in a different tier, with different cost sharing?

• Do any of your drugs have new restrictions, such as needing approval from us before you fill your prescription?

• Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy?

• Review the 2021 Drug List and look in Section [insert section number] for information about changes to our drug coverage.

• Your drug costs may have risen since last year. Talk to your doctor about lower cost alternatives that may be available for you; this may save you in annual out-of-pocket costs throughout the year. To get additional information on drug prices visit go.medicare.gov/drugprices. These dashboards highlight which manufacturers have been increasing their prices and also show other year-to-year drug price information. Keep in mind that your plan benefits will determine exactly how much your own drug costs may change.

• Check to see if your doctors and other providers will be in our network next year.

• Are your doctors, including specialists you see regularly, in our network?

• What about the hospitals or other providers you use?

• Look in Section [insert section number] for information about our Provider Directory.

• Think about your overall health care costs.

• How much will you spend out-of-pocket for the services and prescription drugs you use regularly?

• How much will you spend on your premium and deductibles?

• How do your total plan costs compare to other Medicare coverage options?

• Think about whether you are happy with our plan.

2. COMPARE: Learn about other plan choices

• Check coverage and costs of plans in your area.

• Use the personalized search feature on the Medicare Plan Finder at www.medicare.gov/plan-compare website.

• Review the list in the back of your Medicare & You handbook.

• Look in Section [edit section number as needed] 4.2 to learn more about your choices.

• Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.

3. CHOOSE: Decide whether you want to change your plan

• If you want to keep [insert plan name], you don’t need to do anything. You will stay in [insert plan name].

• To change to a different plan that may better meet your needs, you can switch plans between October 15 and December 7.

[I-SNPs serving institutionalized individuals: May replace the above bullet with the below bullet. Otherwise, delete the below bullet:

• To change to a different plan that may better meet your needs, you can switch plans or switch to Original Medicare (either with or without a separate Medicare prescription drug plan) at any time.]

[I-SNPs: Delete the ENROLL section below if not applicable]

4. ENROLL: To change plans, join a plan between October 15 and December 7, 2020

• If you don’t join another plan by December 7, 2020, you will stay in [insert 2020 plan name]. [If the plan is being crosswalked, replace previous sentence with: If you don’t join another plan by December 7, 2020, you will be enrolled in [insert 2021 plan name].]

• If you join another plan by December 7, 2020, your new coverage will start on January 1, 2021. You will be automatically disenrolled from your current plan.

Additional Resources

• [Plans that meet the 5% alternative language threshold insert: This document is available for free in [insert languages that meet the 5% threshold].

• Please contact our Member Services number at [insert member services phone number] for additional information. (TTY users should call [insert TTY number].) Hours are [insert days and hours of operation].

• [Plans must insert language about availability of alternate formats (e.g., Braille, large print, audio tapes) as applicable.]

• Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.

About [insert 2021 plan name]

• [Insert Federal contracting statement]

• When this booklet says “we,” “us,” or “our,” it means [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document]. When it says “plan” or “our plan,” it means [insert 2021 plan name].

[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID] File & Use [MMDDYYYY]]

Summary of Important Costs for 2021

The table below compares the 2020 costs and 2021 costs for [insert 2021 plan name] in several important areas. Please note this is only a summary of changes. A copy of the Evidence of Coverage is located on our website at [insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You may also call Member Services to ask us to mail you an Evidence of Coverage.

[If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the 2020 Medicare amounts and must insert: These are 2020 cost-sharing amounts and may change for 2021. [Insert plan name] will provide updated rates as soon as they are released. Member cost-sharing amounts may not be left blank.]

Cost	2020 (this year)	2021 (next year)
Monthly plan premium* * Your premium may be higher or lower than this amount. See Section [edit section number as needed] 2.1 for details.	[Insert 2020 premium amount]	[Insert 2021 premium amount]
[Plans with no deductible may delete this row.] Deductible	[Insert 2020 deductible amount]	[Insert 2021 deductible amount]
Maximum out-of-pocket amount This is the most you will pay out-of-pocket for your covered [insert if applicable: Part A and Part B] services. (See Section [edit section number as needed] 2.2 for details.)	[Insert 2020 MOOP amount]	[Insert 2021 MOOP amount]
Doctor office visits	Primary care visits: [insert 2020 cost-sharing for PCPs] per visit Specialist visits: [insert 2020 cost-sharing for specialists] per visit	Primary care visits: [insert 2021 cost-sharing for PCPs] per visit Specialist visits: [insert 2021 cost-sharing for specialists] per visit
Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.	[Insert 2020 cost-sharing]	[Insert 2021 cost-sharing]
Part D prescription drug coverage (See Section [edit section number as needed] 2.6 for details.)	Deductible: [Insert 2020 deductible amount] [Copayment/Coinsurance as applicable] during the Initial Coverage Stage: Drug Tier 1: [Insert 2020 cost-sharing] [Repeat for all drug tiers.]	Deductible: [Insert 2021 deductible amount] [Copayment/Coinsurance as applicable] during the Initial Coverage Stage: Drug Tier 1: [Insert 2021 cost-sharing] [Repeat for all drug tiers.]

Annual Notice of Changes for 2021
Table of Contents

Summary of Important Costs for 2021 1

SECTION 1 We Are Changing the Plan’s Name 4

SECTION 1 Unless You Choose Another Plan, You Will Be Automatically Enrolled in [insert 2021 plan name] in 2021 4

SECTION 2 Changes to Benefits and Costs for Next Year 5

Section 2.1 – Changes to the Monthly Premium 5

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount 5

Section 2.3 – Changes to the Provider Network 6

Section 2.4 – Changes to the Pharmacy Network 7

Section 2.5 – Changes to Benefits and Costs for Medical Services 8

Section 2.6 – Changes to Part D Prescription Drug Coverage 9

SECTION 3 Administrative Changes 16

SECTION 4 Deciding Which Plan to Choose 16

Section 4.1 – If you want to stay in [insert 2021 plan name] 16

Section 4.2 – If you want to change plans 17

SECTION 5 Deadline for Changing Plans 17

SECTION 6 Programs That Offer Free Counseling about Medicare 18

SECTION 7 Programs That Help Pay for Prescription Drugs 18

SECTION 8 Questions? 19

Section 8.1 – Getting Help from [insert 2021 plan name] 19

Section 8.2 – Getting Help from Medicare 20

[If Section 1 does not apply, plans should omit it and renumber remaining sections as needed.]

SECTION 1 We Are Changing the Plan’s Name

[Plans that are changing the plan name, as approved by CMS, include Section 1, using the section title above and the following text:

On January 1, 2021, our plan name will change from [insert 2020 plan name] to [insert 2021 plan name].

[Insert language to inform members if they will receive new ID cards and how, as well as if the name change will impact any other member communication.]]

SECTION 1 Unless You Choose Another Plan, You Will Be Automatically Enrolled in [insert 2021 plan name] in 2021

[If the member is being enrolled into another plan due to a consolidation, include Section 1, using the section title above and the text below. It is additionally expected that, as applicable throughout the ANOC, every plan/sponsor that cross walks a member from a non-renewed plan to a consolidated renewal plan will compare benefits and costs, including cost-sharing for drug tiers, from that members previous plan to the consolidated plan.]

On January 1, 2021, [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document] will be combining [insert 2020 plan name] with one of our plans, [insert 2021 plan name].

If you do nothing to change your Medicare coverage by December 7, 2020, we will automatically enroll you in our [insert 2021 plan name]. This means starting January 1, 2021, you will be getting your medical and prescription drug coverage through [insert 2021 plan name]. If you want to, you can change to a different Medicare health plan. You can also switch to Original Medicare. If you want to change plans, you can do so between October 15 and December 7. If you are eligible for Extra Help, you may be able to change plans during other times.

The information in this document tells you about the differences between your current benefits in [insert 2020 plan name] and the benefits you will have on January 1, 2021 as a member of [insert 2021 plan name].

SECTION 2 Changes to Benefits and Costs for Next Year

Section 2.1 – Changes to the Monthly Premium

[Plans may add a row to this table to display changes in premiums for optional supplemental benefits.]

[Plans that include a Part B premium reduction benefit may insert a row to describe the change in the benefit.]

Cost	2020 (this year)	2021 (next year)
Monthly premium [Plans that include a Part B premium reduction benefit may modify this row to describe the change in the benefit. If there are no changes from year to year, plans may indicate in the column that there is no change for the upcoming benefit year.] (You must also continue to pay your Medicare Part B premium.)	[Insert 2020 premium amount]	[Insert 2021 premium amount]

• Your monthly plan premium will be more if you are required to pay a lifetime Part D late enrollment penalty for going without other drug coverage that is at least as good as Medicare drug coverage (also referred to as “creditable coverage”) for 63 days or more.

• If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage.

• Your monthly premium will be less if you are receiving “Extra Help” with your prescription drug costs. Please see Section 7 regarding “Extra Help” from Medicare.

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount

[Plans that include the costs of supplemental benefits (e.g., POS benefits) in the MOOP limit may revise this information as needed.]

To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket” during the year. This limit is called the “maximum out-of-pocket amount.” Once you reach this amount, you generally pay nothing for covered [insert if applicable: Part A and Part B] services for the rest of the year.

Cost	2020 (this year)	2021 (next year)
Maximum out-of-pocket amount Your costs for covered medical services (such as copays [insert if plan has a deductible: and deductibles]) count toward your maximum out-of-pocket amount. [Plans with no premium may modify the following sentence as needed] Your plan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount. [If there are no changes from year to year, plans may indicate in the column that there is no change for the upcoming benefit year.]	[Insert 2020 MOOP amount]	[Insert 2021 MOOP amount] Once you have paid [insert 2021 MOOP amount] out-of-pocket for covered [insert if applicable: Part A and Part B] services, you will pay nothing for your covered [insert if applicable: Part A and Part B] services for the rest of the calendar year.

Section 2.3 – Changes to the Provider Network

[Insert applicable section: For a plan that has changes in its provider network] There are changes to our network of providers for next year. [Insert if applicable: We included a copy of our Provider Directory in the envelope with this booklet.] An updated Provider Directory is located on our website at [insert URL]. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. Please review the 2021 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.

OR

[For a plan that will have a higher than normal number of providers either leaving and/or joining its network] Our network has changed more than usual for 2021. [Insert if applicable: We included a copy of our Provider Directory in the envelope with this booklet.] An updated Provider Directory is located on our website at [insert URL]. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. We strongly suggest that you review our current Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are still in our network.

It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections summarized below:

• Even though our network of providers may change during the year, we must furnish you with uninterrupted access to qualified doctors and specialists.

• We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.

• We will assist you in selecting a new qualified provider to continue managing your health care needs.

• If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.

• If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.

• If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider to manage your care.

Section 2.4 – Changes to the Pharmacy Network

Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. [Insert if applicable: Our network includes pharmacies with preferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharing offered by other network pharmacies for some drugs.] 

[Insert applicable section: For a plan that has changes in its pharmacy network] There are changes to our network of pharmacies for next year. [Insert if applicable: We included a copy of our Pharmacy Directory in the envelope with this booklet.] An updated Pharmacy Directory is located on our website at [insert URL]. You may also call Member Services for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2021 Pharmacy Directory to see which pharmacies are in our network.

OR

[For a plan that will have a higher than normal number of pharmacies leaving its pharmacy network] Our network has changed more than usual for 2021. [Insert if applicable: We included a copy of our Pharmacy Directory in the envelope with this booklet.] An updated Pharmacy Directory is located on our website at [insert URL]. You may also call Member Services for updated provider information or to ask us to mail you a Pharmacy Directory. We strongly suggest that you review our current Pharmacy Directory to see if your pharmacy is still in our network.

Section 2.5 – Changes to Benefits and Costs for Medical Services

[If there are no changes in benefits or in cost-sharing, revise heading to “There are no changes to your benefits or amounts you pay for medical services” and replace the rest of this section with: Our benefits and what you pay for these covered medical services will be exactly the same in 2021 as they are in 2020.]

We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2021 Evidence of Coverage.

[The table must include: (1) all new benefits that will be added or 2020 benefits that will end for 2021, including any new optional supplemental benefits (plans must indicate these optional supplemental benefits are available for an extra premium); (2) new/changing limitations or restrictions, including prior authorization for CY2021 Part C benefits; and (3) all changes in cost-sharing for 2021 for covered medical services, including any changes to service category out-of-pocket maximums and cost-sharing for optional supplemental benefits (plans must indicate these optional supplemental benefits are available for an extra premium).]

[If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the 2020 Medicare amounts and must insert: These are 2020 cost-sharing amounts and may change for 2021. [Insert plan name] will provide updated rates as soon as they are released. Member cost-sharing amounts may not be left blank.]

Cost	2020 (this year)	2021 (next year)
[Insert benefit name]	[For benefits that were not covered in 2020 insert: [insert benefit name] is not covered.] [For benefits with a copayment insert: You pay a $[insert 2020 copayment amount] copay [insert language as needed to accurately describe the benefit, e.g., “per office visit”].] [For benefits with a coinsurance insert: You pay [insert 2020 coinsurance percentage]% of the total cost [insert language as needed to accurately describe the benefit, e.g., “for up to one visit per year”].]	[For benefits that are not covered in 2021 insert: [insert benefit name] is not covered.] [For benefits with a copayment insert: You pay a $[insert 2021 copayment amount] copay [insert language as needed to accurately describe the benefit, e.g., “per office visit”].] [For benefits with a coinsurance insert: You pay [insert 2021 coinsurance percentage]% of the total cost [insert language as needed to accurately describe the benefit, e.g., “for up to one visit per year”].]
[Insert benefit name]	[Insert 2020 cost/coverage, using format described above.]	[Insert 2021 cost/coverage, using format described above.]

Section 2.6 – Changes to Part D Prescription Drug Coverage

Changes to Our Drug List

Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is [insert: in this envelope] OR [insert: provided electronically]. [If including an abridged formulary, add the following language: The Drug List [insert: included in this envelope] OR [insert: provided electronically] includes many – but not all – of the drugs that we will cover next year. If you don’t see your drug on this list, it might still be covered. You can get the complete Drug List by calling Member Services (see the back cover) or visiting our website ([insert URL]).]

[Plans with no changes to covered drugs, tier assignment, or restrictions may replace the rest of this section with: We have not made any changes to our Drug List for next year. The drugs included on our Drug List will be the same in 2021 as in 2020. However, we are allowed to make changes to the Drug List from time to time throughout the year, with approval from Medicare or if a drug has been withdrawn from the market by either the FDA or a product manufacturer.]

[Plans that are not offering indication based formulary design should delete this section] Certain drugs may be covered for some medical conditions, but are considered non-formulary for other medical conditions. Drugs that are covered for only select medical conditions will be identified on our Drug List and in Medicare Plan Finder, along with the specific medical conditions that they cover.

We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions.

If you are affected by a change in drug coverage, you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. [Plans may omit the following sentence if they do not have an advance transition process for current members.] We encourage current members to ask for an exception before next year.

  • To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Member Services.

• Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Member Services to ask for a list of covered drugs that treat the same medical condition.

[Plans may omit this if all current members will be transitioned in advance for the following year.] In some situations, we are required to cover a temporary supply of a non-formulary drug in the first 90 days of the plan year or the first 90 days of membership to avoid a gap in therapy. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.]

[Plans may include additional information about processes for transitioning current members to formulary drugs when your formulary changes relative to the previous plan year.]

[Include language to explain whether current formulary exceptions will still be covered next year or a new one needs to be submitted.]

Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are allowed by Medicare rules.

[Plan sponsors implementing for the first time in 2021 the option to immediately replace brand name drugs with their new generic equivalents, that otherwise meet the requirements, should insert the following: Starting in 2021, we may immediately remove a brand name drug on our Drug List if, at the same time, we replace it with a new generic drug on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions or both.

This means, for instance, if you are taking a brand name drug that is being replaced or moved to a higher cost-sharing tier, you will no longer always get notice of the change 30 days before we make it or get a month’s supply of your brand name drug at a network pharmacy. If you are taking the brand name drug, you will still get information on the specific change we made, but it may arrive after the change is made.]

When we make these changes to the Drug List during the year, you can still work with your doctor (or other prescriber) and ask us to make an exception to cover the drug. We will also continue to update our online Drug List as scheduled and provide other required information to reflect drug changes. (To learn more about changes we may make to the Drug List, see Chapter 5, Section 6 of the Evidence of Coverage.)

Changes to Prescription Drug Costs

[Plans that enroll partial dual eligible beneficiaries should delete the following paragraph for QDWI beneficiaries.] Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information about costs for Part D prescription drugs [insert as applicable: may OR does] not apply to you. [If not applicable, omit information about the LIS Rider.] We [insert as appropriate: have included OR sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug costs. If you receive “Extra Help” and [if plan sends LIS Rider with ANOC, insert: didn’t receive this insert with this packet,] [if plan sends LIS Rider separately from the ANOC, insert: haven’t received this insert by [insert date],] please call Member Services and ask for the “LIS Rider.”

There are four “drug payment stages.” How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.)

The information below shows the changes for next year to the first two stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage, which is located on our website at [insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You may also call Member Services to ask us to mail you an Evidence of Coverage.)

Changes to the Deductible Stage

Stage	2020 (this year)	2021 (next year)
Stage 1: Yearly Deductible Stage During this stage, you pay the full cost of your [insert as applicable: Part D OR brand name OR [tier name(s)]] drugs until you have reached the yearly deductible. [Plans with no deductible, omit text above.]	The deductible is $[insert 2020 deductible]. [Plans with no deductible replace the text above with: Because we have no deductible, this payment stage does not apply to you.] [Plans with tiers excluded from the deductible in 2020 and/or 2021 insert the following:] During this stage, you pay [insert cost-sharing amount that a member would pay in a tier(s) that is exempted from the deductible] cost-sharing for drugs on [insert name of tier(s) excluded from the deductible] and the full cost of drugs on [insert name of tier(s) where copayments apply] until you have reached the yearly deductible.	The deductible is $[insert 2021 deductible]. [Plans with no deductible replace the text above with: Because we have no deductible, this payment stage does not apply to you.] [Plans with tiers excluded from the deductible in 2020 and/or 2021 insert the following:] During this stage, you pay [insert cost-sharing amount that a member would pay in a tier(s) that is exempted from the deductible] cost-sharing for drugs on [insert name of tier(s) excluded from the deductible] and the full cost of drugs on [insert name of tier(s) where copayments apply] until you have reached the yearly deductible.

Changes to Your Cost-sharing in the Initial Coverage Stage

[Plans that are changing the cost-sharing from coinsurance to copayment or vice versa from 2020 to 2021 insert: For drugs on [insert name of tier(s)], your cost-sharing in the initial coverage stage is changing from [insert whichever is appropriate: copayment to coinsurance OR coinsurance to copayment.] Please see the following chart for the changes from 2020 to 2021.]

To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage.

[Plans must list all drug tiers in the table below and show costs for a one-month supply filled at a network retail pharmacy. Plans that have pharmacies that provide preferred cost-sharing must provide information on both standard and preferred cost-sharing using the second alternate chart. Plans without drug tiers may revise the table as appropriate.]

Stage	2020 (this year)	2021 (next year)
Stage 2: Initial Coverage Stage [Plans with no deductible delete the first sentence] Once you pay the yearly deductible, you move to the Initial Coverage Stage. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. [Plans that are changing the cost-sharing from a copayment to coinsurance or vice versa from 2020 to 2021 insert for each applicable tier: For 2020 you paid [insert as appropriate: a $[xx] copayment OR [xx]% coinsurance] for drugs on [insert tier name]. For 2021 you will pay [insert as appropriate: a $[xx] copayment” OR “[xx]% coinsurance] for drugs on this tier.]	Your cost for a one-month [Plans that are changing the number of days in their one-month supply from 2020 to 2021 insert “([xx]-day)” rather than “one-month”] supply filled at a network pharmacy with standard cost-sharing: [Insert name of Tier 1]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Insert name of Tier 2]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Repeat for all tiers]	Your cost for a one-month [Plans that are changing the number of days in their one-month supply from 2020 to 2021 insert “([xx]-day)” rather than “one-month”] supply filled at a network pharmacy with standard cost-sharing: [Insert name of Tier 1]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Insert name of Tier 2]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Repeat for all tiers]
Stage 2: Initial Coverage Stage (continued) The costs in this row are for a one-month ([insert number of days in a one-month supply]-day) supply when you fill your prescription at a network pharmacy that provides standard cost-sharing. [Plans that are changing the number of days in their one-month supply from 2020 to 2021 insert: The number of days in a one-month supply has changed from 2020 to 2021 as noted in the chart.] For information about the costs [insert as applicable: for a long-term supply; at a network pharmacy that offers preferred cost-sharing; or for mail-order prescriptions], look in Chapter 6, Section 5 of your Evidence of Coverage. [Insert if applicable: We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.]	______________ Once [insert as applicable: your total drug costs have reached $[insert 2020 initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2020 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).]	______________ Once [insert as applicable: your total drug costs have reached $[insert 2021 initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2021 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).]

[Plans with pharmacies that offer standard and preferred cost-sharing may replace the chart above with the one below to provide both cost-sharing rates.]

	2020 (this year)	2021 (next year)
Stage 2: Initial Coverage Stage [Plans with no deductible delete the first sentence] Once you pay the yearly deductible, you move to the Initial Coverage Stage. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. [Plans that are changing the cost-sharing from a copayment to coinsurance or vice versa from 2020 to 2021 insert for each applicable tier: For 2020 you paid [insert as appropriate: a $[xx] copayment OR [xx]% coinsurance] for drugs on this tier. For 2021 you will pay [insert as appropriate: a $[xx] copayment OR [xx]% coinsurance] for drugs on this tier.] The costs in this row are for a one-month ([insert number of days in a one-month supply]-day) supply when you fill your prescription at a network pharmacy. [Plans that are changing the number of days in their one-month supply from 2020 to 2021 insert: The number of days in a one-month supply has changed from 2020 to 2021 as noted in the chart.] For information about the costs [insert as applicable: for a long-term supply or for mail-order prescriptions], look in Chapter 6, Section 5 of your Evidence of Coverage. [Insert if applicable: We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.]	Your cost for a one-month [Plans that are changing the number of days in their one-month supply from 2020 to 2021 insert: “([xx]-day)” rather than “one-month”] supply at a network pharmacy: [Insert name of Tier 1]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Insert name of Tier 2]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Repeat for all tiers] ______________ Once [insert as applicable: your total drug costs have reached $[insert 2020 initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2020 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).]	Your cost for a one-month [Plans that are changing the number of days in their one-month supply from 2020 to 2021 insert “([xx]-day)” rather than “one-month”] supply at a network pharmacy: [Insert name of Tier 1]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Insert name of Tier 2]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Repeat for all tiers] ______________ Once [insert as applicable: your total drug costs have reached $[insert 2021 initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2021 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).]

Changes to the Coverage Gap and Catastrophic Coverage Stages

The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage Stage – are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. [Sponsors that are changing the cost-sharing from coinsurance to copayment or vice versa from 2020 to 2021 insert the following sentence. If many changes are being made, it may be repeated as necessary: For [insert coverage stage involved] Coverage Stage, for drugs on Tiers [xx] [insert tiers], your cost-sharing is changing from [insert whichever is appropriate: a copayment to coinsurance OR coinsurance to a copayment].] For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage.

SECTION 3 Administrative Changes

[This section is optional. Plans with administrative changes that impact members (e.g., a change in options for paying the monthly premium, change in contract or PBP number) may insert this section and include an introductory sentence that explains the general nature of the administrative changes. Plans that choose to omit this section should renumber the remaining sections as needed.]

Cost	2020 (this year)	2021 (next year)
[Insert a description of the administrative process/item that is changing]	[Insert 2020 administrative description]	[Insert 2021 administrative description]
[Insert a description of the administrative process/item that is changing]	[Insert 2020 administrative description]	[Insert 2021 administrative description]

SECTION 4 Deciding Which Plan to Choose

Section 4.1 – If you want to stay in [insert 2021 plan name]

To stay in our plan you don’t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically stay enrolled as a member of our plan for 2021.

Section 4.2 – If you want to change plans

We hope to keep you as a member next year but if you want to change for 2021 follow these steps:

Step 1: Learn about and compare your choices

• You can join a different Medicare health plan timely,

• OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan. If you do not enroll in a Medicare drug plan, please see Section 2.1 regarding a potential Part D late enrollment penalty.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2021, call your State Health Insurance Assistance Program (see Section [edit section number as needed] 6), or call Medicare (see Section [edit section number as needed] 8.2).

You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to www.medicare.gov/plan-compare. Here, you can find information about costs, coverage, and quality ratings for Medicare plans.

[Plans may choose to insert if applicable: As a reminder, [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document] offers other [insert as applicable: Medicare health plans AND/OR Medicare prescription drug plans. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts.]]

Step 2: Change your coverage

• To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from [insert 2021 plan name].

• To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from [insert 2021 plan name].

• To change to Original Medicare without a prescription drug plan, you must either:

• Send us a written request to disenroll. Contact Member Services if you need more information on how to do this (phone numbers are in Section [edit section number as needed] 8.1 of this booklet).

• – or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.

SECTION 5 Deadline for Changing Plans

If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2021.

Are there other times of the year to make a change?

In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get “Extra Help” paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area may be allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage.

If you enrolled in a Medicare Advantage plan for January 1, 2021, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2021. For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage.

[I-SNPs serving institutionalized individuals: May replace the paragraph above with the following:

You can change your Medicare coverage at any time. You can change to any other Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without a separate Medicare prescription drug plan) at any time.]

SECTION 6 Programs That Offer Free Counseling about Medicare

[Organizations offering plans in multiple states: Revise this section to use the generic name (“State Health Insurance Assistance Program”) when necessary, and include a list of names, phone numbers, and addresses for all SHIPs in your service area.]

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In [insert state], the SHIP is called [insert state-specific SHIP name].

[Insert state-specific SHIP name] is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. [Insert state-specific SHIP name] counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call [insert state-specific SHIP name] at [insert SHIP phone number]. [Plans may insert the following: You can learn more about [insert state-specific SHIP name] by visiting their website ([insert SHIP website]).]

SECTION 7 Programs That Help Pay for Prescription Drugs

You may qualify for help paying for prescription drugs. [Plans in states without SPAPs, delete the next sentence] Below we list different kinds of help:

• “Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if you qualify, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;

  • The Social Security Office at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call, 1-800-325-0778 (applications); or

  • Your State Medicaid Office (applications).

• [Plans without an SPAP in their state(s), should delete this bullet.] [Organizations offering plans in multiple states: Revise this bullet to use the generic name (“State Pharmaceutical Assistance Program”) when necessary, and include a list of names for all SPAPs in your service area.] Help from your state’s pharmaceutical assistance program. [Insert state name] has a program called [insert state-specific SPAP name] that helps people pay for prescription drugs based on their financial need, age, or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section [edit section number as needed] 6 of this booklet).

• [Plans with an ADAP in their state(s) that do NOT provide Insurance Assistance should delete this bullet.] [Plans with no Part D drug cost-sharing should delete this section.] Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance through the [insert State-specific ADAP name and information]. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call [insert State-specific ADAP contact information].

SECTION 8 Questions?

Section 8.1 – Getting Help from [insert 2021 plan name]

Questions? We’re here to help. Please call Member Services at [insert member services phone number]. (TTY only, call [insert TTY number]). We are available for phone calls [insert days and hours of operation]. [Insert if applicable: Calls to these numbers are free.]

Read your 2021 Evidence of Coverage (it has details about next year's benefits and costs)

This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2021. For details, look in the 2021 Evidence of Coverage for [insert 2021 plan name]. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is located on our website at [insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You may also call Member Services to ask us to mail you an Evidence of Coverage.

Visit our Website

You can also visit our website at [insert URL]. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List).

Section 8.2 – Getting Help from Medicare

To get information directly from Medicare:

Call 1-800-MEDICARE (1-800-633-4227)

You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Visit the Medicare Website

You can visit the Medicare website (www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to www.medicare.gov/plan-compare).

Read Medicare & You 2021

You can read the Medicare & You 2021 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don’t have a copy of this booklet, you can get it at the Medicare website (www.medicare.gov) or by calling 1‑800‑MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1‑877‑486‑2048.

OMB Approval 0938-1051 (Expires: December 31, 2021)