CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sect

2022 Model Part D Explanation of Benefits
I.

General instructions for plans ............................................................................................................................................................. 2

II.

Model language for the cover page ..................................................................................................................................................... 4

III.

Model language for Section 1 ............................................................................................................................................................. 6

IV.

Model language for Section 2 ............................................................................................................................................................14

V.

Model language for Section 3 ............................................................................................................................................................31

VI.

Model language for Section 4 ............................................................................................................................................................33

VII.

Model language for Sections 5 and 6 .................................................................................................................................................37

APPENDIX (Exhibits with examples)...........................................................................................................................................................39

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I.

General instructions for plans

[Instructions for plans:
•

This is a Part D model EOB. Your EOB must include all model
language exactly as provided.
o Minor grammar or punctuation changes, as well as
changes in font type or color, are permissible.
o References to a specific plan name in brackets may be
replaced with generic language such as “our plan.”
o References to Member Services can be changed to the
appropriate name your plan uses.
o References to the plan’s Supplemental Drug Coverage
can be changed to the appropriate name your plan
uses. (This is coverage for non-Part D drugs.)
o References to “cost-sharing tiers” may be expanded to
include additional description, including the
standardized names of the tiers used by your plan.
o References to “brand-name/tier-level” deductible can
be changed to the appropriate name your plan uses.
o Unless specific formatting instructions for dates have
been given, plans may use their preferred method of
formatting the date (such as “mm/dd/yy”).
o References to “calendar year” may be changed to
“plan year.”

•

Medicare-Medicaid Plans: If choosing the Part D Model EOB,
CMS requires that the EOB must contain all information and
follow all instructions within the CMS model. CMS expects
that Medicaid-covered drugs will be included in the model.

•

Italicized blue text in square brackets is information for the
plans. Do not include in EOB.

•

Non-italicized blue text in square brackets is text that can be
inserted or used as replacement text in the EOB. Use it as
applicable.

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2

•

References to “TrOOP” mean the total of all drug costs paid
by the enrollee, the LIS subsidy, and all others whose payments
count toward the enrollee’s out-of-pocket costs.

•

References to “Total Drug Costs” mean “Gross Drug Spend,”
i.e., the total of all drug costs paid, including by the plan, the
enrollee, the LIS subsidy, and all others who paid on the
enrollee’s behalf.

•

Plans may use the optional notes that give members additional
information related to a prescription, such as notes for 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.

•

Drug Pricing Information (Drug Price & Price Change):
Pursuant to 42 CFR § 423.128(e), Part D sponsors must include
the cumulative percentage increase (if any) in the negotiated
price since the first claim of the current benefit year and also
provide the beneficiary with lower cost therapeutic alternatives
when available as determined by the plan. )
o The Drug Price column shows the member the total cost
of each drug (including member, plan, and other
payments paid) from when the prescription was first filled
during the benefit year. The Price Change shows the
percentage change of the drug price from when the
prescription was first filled during the current benefit
year.
o Plans have the flexibility to determine the appropriate
number of lower cost therapeutic alternative drugs that
are listed; however, plans must provide at least (1) drug
for each filled prescription if there is a lower cost
therapeutically equivalent drug available. Plans should
use their clinical expertise when deciding to identify
drugs with lower cost sharing that may not be
appropriate for the beneficiary.

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•

Prior year fills that do not apply to the current EOB or current
year gross drug spend or TrOOP do not need to be included in
this EOB and would not require a separate EOB.

•

When a beneficiary disenrolls from a plan during the plan
year, the sponsor must send an EOB to the beneficiary after
disenrollment if any claims are processed prior to the
beneficiary disenrolling. For example, if a beneficiary
disenrolls at the end of August and the plan processes claims
in months prior to disenrollment, the disenrolling plan must
send the beneficiary a final EOB.

•

References to “Extra Help” mean LIS.

•

The first time the plan name is mentioned, the plan type
designation (i.e., HMO, PPO, etc.) must be identified (see
model language for the cover).

•

If the total drug costs and out-of-pocket costs change due to an
automatic TrOOP balance transfer for the current year the
plan must send the EOB depicting the changes to the totals in
the year- to-date totals in sections 1 and totals in 3. If a plan
transfer has occurred in a given month, the EOB must be sent
even if there were no prescriptions filled in the prior month.
The note regarding the transferred amounts must remain in
Section 3 for the rest of the year.

•

To accommodate use of standard window envelopes for ease of
mailing, the model language includes a version of the cover
page that uses portrait orientation. There is also a version of
the cover that uses landscape orientation. Plans may use either
version.

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•

Except for the cover page, all other pages are to be formatted
in landscape orientation.

3

o To keep line lengths easy to read, the landscapeoriented cover page and sections 3 through 7 are to be
formatted as two-column text.
o To help conserve space, the document has been
designed so that Sections 3 through 7 can be printed as
a continuous flow of two-column headings and text.
o To help conserve space, the document can be printed
double-sided.
•

The document must include page numbers. If desired, plans
may add a header or footer that includes some or all of the
following information: member identifiers; month and year;
contact information; page number.

•

Charts that continue from one page to the next must be marked
with “continue” at the bottom on the page that continues. In an
actual EOB, rows of a chart must not break across the page (in
the model language in this document, rows sometimes break
across a page because of the instructions and substitution text).

•

For examples that show versions of the cover page and each
section of the EOB, see Exhibits A through F in the Appendix.
These exhibits will help you visualize what the document will
look like when substitution text is applied for various
situations. In addition, Appendix G shows an example of a
complete EOB.]

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II.

Model language for the cover page

4

[NOTE TO PLANS ABOUT THE COVER PAGE:
•

This page can be formatted in either portrait or landscape orientation. For examples of both formats, see Exhibit A in the Appendix.

•

Instructions to plans are shown below on the landscape version of the cover. These same instructions apply if the portrait version is used.]

•

Pursuant to 42 CFR §423.2267, applicable disclaimers must be included in this document.

[Insert plan name and/or logo.]
[Insert mailing date.]
[Insert beneficiary name.]
[Insert beneficiary mailing address.]
[Insert plan name followed by model type shown
in parentheses, e.g., “(HMO)”] is operated by
[insert plan sponsor name and mailing address].
[If desired, plans may insert member ID number
and/or other member numbers typically used in
member communications, for easy reference by the
plan member. Plans may include one or more of
these identifiers in a header to this document,
together with the month and year and the page
number.]

Need large print or another format?
To get this material in other formats, or ask for
language translation services, call [insert plan
name] Member Services (the number is on this
page).
For languages other than English:

Your Monthly Prescription Drug Summary
For [insert month, year using a format that spells out the name
of the month and gives the full year, e.g., “January 2022”]
This summary is your “Explanation of Benefits” (EOB) for your Medicare
prescription drug coverage (Part D). Please review this summary and keep it
for your records. This is not a bill.
Here are the sections in this summary:
SECTION 1. Your prescriptions during the past month
SECTION 2. Which “drug payment stage” are you in?
SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and
definitions)
SECTION 4. Updates to the plan’s Drug List that affect drugs you take
SECTION 5. If you see mistakes on this summary or have questions, what
should you do?
SECTION 6. Important things to know about your drug coverage and your rights

[insert plan name] Member Services
If you have questions or need help, call us [insert days of week and
calling hours]. Calls to these numbers are free.
[Insert phone number; plan may add local phone number if desired.]

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TTY users call: [insert TTY number]

5

On the Web at: [insert URL]

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III. Model language for Section 1
[NOTE TO PLANS ABOUT SECTION 1:

•
•

The amounts to be used for “you paid” are the final amounts after other payments (those made by programs, organizations, or other
plans).
Do not provide information in the Part D EOB about drugs or supplies that would be covered for a beneficiary in original Medicare
under Parts A and/or B; for an enrollee in a Part C plan under the plan’s Part A/B coverage; or otherwise covered under nonMedicare insurance.]

SECTION 1. Your prescriptions during the past month
•

•

•

Chart 1 shows your prescriptions for covered Part D drugs for the past month. [If member has
filled prescriptions for non-Part D drugs covered by the plan’s supplemental drug coverage
during the past month, include Chart 2 in the EOB and add the following sentence here:
(Prescriptions for drugs covered by our plan’s Supplemental Drug Coverage are shown separately
in Chart 2.)]
Please look over this information about your prescriptions and check to see that it’s
correct. If you have any questions or think there is a mistake, Section 5 shows you what to do.
Drug Pricing Information (Drug Price & Price Change)
o The Drug Price shows the cost of each drug (including what you, your plan and other programs paid). The Price Change
shows the percentage of the drug price since it was first filled during this benefit year.
o There may be Lower Cost Therapeutic Alternative drugs (when applicable) listed below some of your current drugs. These
are drugs that may be an alternative to the ones you are taking but with lower cost-sharing or a lower drug price. You may want
to speak with your prescriber to see if the lower cost therapeutic alternative is right for you.

CHART 1.

Your prescriptions for covered Part D drugs
[insert month and year]
[If the EOB is being sent to a member who has not
filled any prescriptions for covered Part D drugs
during the month, plans must (1) insert the
following note in this column: “No prescriptions
for covered Part D drugs this month,” (2) insert
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Plan paid

You paid

[Insert
amount.
Use $0.0if
applicable.]

[Insert
amount.
Use $0.00 if
applicable.]

Other payments

Drug Price
& Price
Change

[Insert amount.
Use $0.00 if
applicable. For
each payment,
identify the payer

[Insert total
drug price,
including what
member, plan,
and other

(made by programs or
organizations; see
Section 3)

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CHART 1.

Your prescriptions for covered Part D drugs
[insert month and year]
amounts of “$0.00” for the columns labeled “Plan
paid,” “You paid” and “Other payments….” and
(3) omit the row with “Totals for the month…” at
the end of this chart.]
[Insert name of drug (other than compound)
followed by quantity, strength, and form, e.g., “25
mg tabs”. Identify compound drugs as such and
provide quantity.]
[Insert date filled]. [Plans should include the name
of the pharmacy if known. Plans may add the
location of the pharmacy, and other additional
pharmacy information if desired, such as “nonnetwork pharmacy.”]
[Insert prescription number], [Insert amount
dispensed as quantity filled and/or days supply,
e.g., “15 tablets”, “30 days supply.”] [Plans may
add additional information about the prescription
if desired.]
[If Section 4 on changes to the formulary contains
a change that applies to a drug listed in Chart 1,
plans must insert a note here to alert the member
that this change has taken place. Use the following
examples as a guide for the text to be used in this
note. Also, see the examples of other notes in
Example 5 of Exhibit B in the Appendix. “NOTE:
Beginning on January 1, 2022, step therapy will be
required for this drug. See Section 4 for details.”]

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Plan paid

You paid

Other payments

Drug Price
& Price
Change

as follows. When
paid by the
Medicare
Coverage Gap
Discount Program
or Extra Help:
“$5.00 (paid by
Medicare
Coverage Gap
Discount
Program), “$5.00
(paid by “Extra
Help”). Plans may
insert other payers
if known. (e.g.,
$10.00 (paid by
Veteran’s
Administration)”.
If payer is not
known, plan should
identify as “other
payer.”

programs
paid.]

(made by programs or
organizations; see
Section 3)

[Insert
percentage
change
(increase or
decrease) in
price of drug
since first fill.]

For an illustration,
see Example 2 in
Exhibit B in the
Appendix.]

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CHART 1.

Your prescriptions for covered Part D drugs

Plan paid

You paid

[Insert total
amount paid by the
plan this month;
use $0.00 if
applicable.]

[Insert total
amount paid by
member this
month; use
$0.00 if
applicable.]

[insert month and year]

Other payments

(made by programs or
organizations; see
Section 3)

Drug Price
& Price
Change

[Insert Lower Cost Therapeutic Alternative(s)]
[Plans have flexibility in number of alternatives
that are appropriate for the member.]
[Plans are encouraged to use the optional notes
that give members additional information related
to a prescription, such as notes that highlight
general price increases for that drug, or when a
payment for a drug does not count toward out-ofpocket costs, or the drug is only partially covered
because it is a compound drug that includes nonPart D drugs.]
TOTALS for the month of [insert month and
year]:

Your “out-of-pocket costs” amount is $[insert
TrOOP for the month. Use “$0.00” if applicable].
(This is the amount you paid this month ([insert
total paid by member for the month. Use “$0.00” if
(total for the
applicable]) plus the amount of “other payments”
month)
made this month that count toward your “out-ofpocket costs” ([insert total of “other payments”
made that count toward the member’s out-of-pocket
costs. Use “$0.00” if applicable]). See definitions
in Section 3.
Your “total drug costs” amount is $[insert Total
Drug Costs for the month; use “$0.00” if
applicable]. (This is the total for this month of all
payments made for your drugs by the plan ([insert
total paid by plan for the month. Use “$0.00” if
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(total for the
month)
[If amount is
not $0.00, and
any of this total
does not count
toward out-ofpocket costs,
add the
following text:
(Of this amount,

[Insert total amount of
“other payments” for the
month; use $0.00 if
applicable.]
(total for the month)
[If amount is not $0.00,
and there are any
payments that do not
count toward out-ofpocket costs, add the
following text: (Of this
amount, $[insert amount
that does count toward
out-of-pocket costs]
counts toward your
“out-of-pocket costs.

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CHART 1.

Your prescriptions for covered Part D drugs

Plan paid

You paid

[insert month and year]
applicable]) and you ([insert total paid by member
for the month; use “$0.00” if applicable]) plus
“other payments” ([insert total of “other payments
for the month; use “$0.00” if applicable]).

$[insert amount
paid that does
count toward
out-of-pocket
costs] counts
toward your
out-of-pocket
costs.)

Plan paid

Other payments

(made by programs or
organizations; see
Section 3)

See definitions in
Section 3.)]

You paid

Year-to-date totals
[insert beginning date for the period
covered by year-to-date, e.g., “1/1/2022”]
through [insert ending date for the
month]
Your year-to-date amount for “out-of-pocket costs”
is $[insert year-to-date TrOOP; use “$0.00” if
applicable].
Your year-to-date amount for “total drug costs” is
$[insert year-to-date Total Drug Costs; use “$0.00” if
applicable].
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Drug Price
& Price
Change

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

[Insert year-to-date
amount of payments
made by the plan; use
$0.00 if applicable.]

[Insert year-to-date
amount paid by the
member; use $0.00 if
applicable.]

[Insert year-to-date total
for “other payments”; use
$0.00 if applicable]

(year-to-date total)

(year-to-date total)[If
total is not $0.00 and
any of this total does

(year-to-date total)

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For more about “out-of-pocket costs” and “total drug
costs,” see Section 3.
[If the member was enrolled in a different plan for Part
D coverage earlier in the year, plans must insert the
following: “NOTE: Your year-to-date totals shown here
include payments of $[insert the TrOOP balance
transferred from prior plan] in out-of-pocket costs and
$[insert amount for Total Drug Costs] in total drug
costs made for your Part D covered drugs when you
were in a different plan earlier this year.”]

not count toward outof-pocket costs, insert:
(Of this amount,
$[insert amount paid
that does count toward
out-of-pocket costs]
counts toward your outof-pocket costs.)]

[If total is not $0.00 and
there are any payments
that do not count toward
out-of-pocket costs, insert:
(Of this amount, $[insert
amount that does count
toward out-of-pocket
costs] counts toward your
“out-of- pocket costs.” See
definitions in Section 3.)]

[Optional: If corrections have been made that affect
amounts shown in previous monthly summaries during
the calendar year, plans may use this space for a
explanatory note: “NOTE: The following [insert
whichever applies: correction has OR corrections have
OR adjustment has OR adjustments have] been made to
amounts that were shown in a monthly summary sent to
you earlier this calendar year: [Plans should insert a
brief explanation of the correction or adjustment that
identifies the change that has been made and provides
relevant dates and a reason for the change, e.g., clerical
error, updated information about the prescription,
decision on an appeal, etc.“ Plans have the flexibility to
report such adjustments or corrections to members
using other means instead of, or in addition to, inserting
this explanatory note into the EOB.]

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[Include Chart 2 only if the EOB is for a plan member who has filled at least one prescription during the month for a non-Part D drug that is
covered by the plan’s Supplemental Drug Coverage.

Do not provide information in the Part D EOB about drugs or supplies that would be covered for a beneficiary in original Medicare under
Parts A and/or B; for an enrollee in a Part C plan under the plan’s Part A/B coverage; or otherwise covered under non-Medicare insurance.]

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CHART 2.
Your prescriptions for drugs covered by our
plan’s Supplemental Drug Coverage
[insert month, year]
• This chart shows your prescriptions for drugs
that are not generally covered by Medicare.

Plan paid

You paid

• These drugs are covered for you under our plan’s

Supplemental Drug Coverage.

[Insert name of drug (other than compound) followed
by quantity, strength, and form, e.g., “25 mg tabs”.
Identify compound drugs as such and provide quantity.]
[Insert date filled]. [Plans should include the name of the
pharmacy if known. Plans may add the location of the
pharmacy, and other additional pharmacy information if
desired, such as “non-network pharmacy.”]

[Insert amount. Use
$0.00 if applicable.]

[Insert amount.
Use $0.00 if
applicable.]

Other payments

(made by programs or
organizations; see
Section 3)
[Insert amount. Use
$0.00 if applicable.
For each payment,
identify the payer if
known. If payer is
not known, identify
as “other payer.”]

[Insert prescription number], [Insert amount dispensed,
as quantity filled and/or days supply, e.g., “15 tablets”,
“30 days supply.”] [Plans may add additional
information about the prescription if desired]
[Plans are encouraged to use the optional notes that give
members additional information related to a
prescription, such as notes that highlight general price
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.]

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CHART 2.
Your prescriptions for drugs covered by our
plan’s Supplemental Drug Coverage
[insert month, year]
• 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.

Totals for the month of [insert month, year]

Plan paid

You paid

Other payments

(made by programs or
organizations; see
Section 3)

[Insert totals for the month under each column. Use $0.00 if applicable]
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.)

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IV.

Model language for Section 2

[NOTE TO PLANS ABOUT SECTION 2: Consistent with the goal of standardizing the EOB document, this section on drug payment stages
always shows all four stages, even though some of these stages will not be applicable to certain plans and/or plan members. When a drug
payment stage is not applicable to members, the model language includes explanatory notes to insert that tell the members that the stage does
not apply to them.
Language in Section 2 is customized to fit the payment stage the member is in. Within each stage, there are wording variations. These include
variations for plan design (e.g., deductible vs. brand-name/tier level only deductible vs. non-deductible, partial coverage during the Coverage
Gap) and for LIS (non-LIS, partial LIS, full LIS). This section can be suppressed when the individual is a full benefit dual eligible individual
and is either institutionalized or receiving home and community based waiver services (LICS level 3).
To make the substitution text easier to follow, this model document presents different versions of Section 2 for each payment stage, with
separate versions for LIS and non-LIS. Versions of Section 2 for non-LIS are shown first, followed by those for LIS.
In addition, for a quick overview of how the language and formatting accents change from one stage to the next, for non-LIS and LIS, see the
examples of Section 2 in Exhibit C in the Appendix.]

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[Use this version of Section 2 for members without LIS who are in the deductible stage]

SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible

STAGE 2
Initial Coverage

STAGE 3
Coverage Gap

STAGE 4
Catastrophic Coverage

[If the plan has a deductible for all
tiers, insert the following three
bullets.]

• During this payment stage,
the plan pays its share of the
cost of your [insert if
applicable: generic/tier
levels] drugs and you (or
others on your behalf) pay
your share of the cost.

• During this payment stage,
you (or others on your
behalf) receive a 70%
manufacturer’s discount on
covered brand name drugs
and the plan will cover
[insert if additional brand
gap coverage: “at least”]
another 5%, so you will
pay [insert if additional
brand gap coverage: “less
than”] 25% of the
negotiated price on brandname drugs. In addition
you pay [insert if
additional generic gap
coverage: “less than”] 25%
of the costs of generic
drugs.

• During this payment stage,
the plan pays most of the
cost for your covered
drugs.

• You begin in this payment stage
when you fill your first prescription
of the calendar year. During this
stage, you (or others on your behalf)
pay the full cost of your drugs.
• You generally stay in this stage until
you (or others on your behalf)
have paid $[insert deductible
amount] for your drugs ($[insert
deductible amount] is the amount of
your deductible).
• As of [insert end date for the month]
you have paid $[insert year-to-date
Total Drug Costs] for your drugs.
[If the plan has a brand-name/tier
level deductible, insert the following
three bullets.]
• During this payment stage, you (or
others on your behalf) pay the full
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• [Insert if applicable: After
you (or others on your
behalf) have met your
[brand-name/tier level]
deductible, the plan pays its
share of the cost of your
[brand-name/tier level]
drugs and you (or others on
your behalf) pay your share
of the cost.]
• You generally stay in this
stage until the amount of
your year-to-date “total
drug costs” (see Section 3)
reaches $[insert initial
coverage limit]. When this
happens, you move to

• You generally stay in this
stage for the rest of the
calendar year (through
December 31, 2022).

• You generally stay in this
stage until the amount of
your year-to-date “out-ofpocket costs” (see Section
3) reaches $7,050. When
this happens, you move to
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cost of your [brand-name/tier level]
drugs.
• You generally pay the full cost of
your [brand-name/tier level] drugs
until you (or others on your behalf}
have paid $[Insert deductible
amount] for your [brand-name/tier
level] drugs ($[Insert deductible
amount] is the amount of your
[brand-name/tier level] deductible.)
• As of [insert end date for the month]
you have paid $[insert year-to-date
Deductible Drug Costs] for your
drugs in the deductible.

payment stage 3, Coverage
Gap.

payment stage 4,
Catastrophic Coverage.

[If the plan has a brandname/tier level deductible,
insert the following bullet.]
• As of [insert end date for
the month] your year-todate “total drug costs”
were $[insert year-to-date
Total Drug Costs]. (See
definitions in Section3.)

What happens next?
Once you (or others on your behalf)
have paid an additional $[insert
additional amount needed to satisfy
the deductible] for your drugs, you
move to the next payment stage
(stage 2, Initial Coverage).

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SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible
[If the plan has no
deductible, replace the text
in this cell with: (Because
there is no deductible for
the plan, this payment stage
does not apply to you.)]
[If the plan has a brandname/tier level deductible,
insert the following two
bullets.]
• During this payment stage,
you (or others on your
behalf) pay the full cost of
your [brand-name/tier
level] drugs.
• You generally pay the full
cost of your [brandname/tier level] drugs until
you (or others on your
behalf) have paid $[insert
deductible amount] for your
[brand-name/tier level]
drugs ($[insert deductible
CMS-10141

STAGE 2
Initial Coverage

STAGE 3
Coverage Gap

STAGE 4
Catastrophic Coverage

• [Insert either: You begin in this
payment stage when you fill your
first prescription of the year.
During this OR During this
payment] stage, the plan pays its
share of the cost of your [insert if
applicable: generic/ tier levels]
drugs and you (or others on your
behalf) pay your share of the cost.

• During this payment stage,
you (or others on your
behalf) receive a 70%
manufacturer’s discount on
covered brand name drugs
and the plan will cover
[insert if additional brand
gap coverage: “at least”]
another 5%, so you will pay
[insert if additional brand
gap coverage: “less than”]
25% of the negotiated price
on brand-name drugs. In
addition you pay [insert if
additional generic gap
coverage: “less than”] 25%
of the costs of generic
drugs.

• During this payment stage,
the plan pays most of the
cost for your covered
drugs.

• [Insert if applicable: After you (or
others on your behalf) have met
your [brand-name/tier level]
deductible, the plan pays its share
of the cost of your [brandname/tier level] drugs and you (or
others on your behalf) pay your
share of the cost.]
• You generally stay in this stage
until the amount of your year-todate “total drug costs” reaches
$[insert initial coverage limit]. As
of [insert end date of month], your
year-to-date “total drug costs” were
$[insert year-to-date Total Drug

• You generally stay in this
stage for the rest of the
calendar year (through
December 31, 2022).

• You generally stay in this
stage until the amount of
your year-to-date “out-ofpocket costs” (see Section
3) reaches $7,050.When
this happens, you move to
OMB Approval No. 0938-0964 (Expires 11/30/2021)

18

amount] is the amount of
your [brand name/tier
level] deductible.)

Costs]. (See definitions in Section
3.)

payment stage 4,
Catastrophic Coverage.

[If the plan has a
deductible for all tiers,
insert the following two
bullets.]
• You begin in this payment
stage when you fill your
first prescription of the
year. During this stage, you
(or others on your behalf)
pay the full cost of your
drugs.
• You generally stay in this
stage until you have paid
$[insert deductible amount]
for your drugs ($[insert
deductible amount] is the
amount of your deductible).
Then you move to payment
stage 2, Initial Coverage.

What happens next?
Once you have an additional
$[insert amount needed in
additional Total Drug Costs to
meet the initial coverage limit] in
“total drug costs,” you move to
the next payment stage (stage 3,
Coverage Gap).

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19

[Use the following version of Section 2 for members without LIS who are in the coverage gap]

SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible
[If the plan has no
deductible, replace the text
in this cell with: (Because
there is no deductible for the
plan, this payment stage
does not apply to you.)]
[If the plan has a brandname/tier level deductible,
insert the following two
bullets.]
• During this payment stage,
you (or others on your
behalf) pay the full cost of
your [brand-name/tier level]
drugs.
• You generally pay the full
cost of your [brandname/tier level] drugs until
you (or others on your
behalf) have paid $[insert
deductible amount] for your
[brand-name/tier level]
drugs ($[insert deductible
amount] is the amount of
CMS-10141

STAGE 2
Initial Coverage

STAGE 3
Coverage Gap

STAGE 4

• [Insert either: You begin in
this payment stage when you
fill your first prescription of
the year. During this OR
During this payment] stage,
the plan pays its share of the
cost of your [insert if
applicable: generic/ tier
levels] drugs and you (or
others on your behalf) pay
your share of the cost.

• During this payment stage,
you (or others on your
behalf) receive a 70%
manufacturer’s discount on
covered brand name drugs
and the plan will cover
[insert if additional brand
gap coverage: “at least”]
another 5%, so you will pay
[insert if additional brand
gap coverage: “less than”]
25% of the negotiated price
on brand-name drugs. In
addition you pay [insert if
additional generic gap
coverage: “less than”] 25%
of the costs of generic drugs.

• During this payment stage,
the plan pays most of the
cost for your covered drugs.

• [Insert if applicable: After
you (or others on your
behalf) have met your
[brand-name/tier level]
deductible, the plan pays its
share of the cost of your
[brand-name/tier level]
drugs and you (or others on
your behalf) pay your share
of the cost.]
• You generally stay in this
stage until the amount of
your year-to-date “total drug
costs” reaches $[insert initial

Catastrophic Coverage

• You generally stay in this
stage for the rest of the
calendar year (through
December 31, 2022).

• You generally stay in this
stage until the amount of
your year-to-date “out-ofpocket costs” reaches
$7,050. As of [insert end
date of month] your year-todate “out-of-pocket costs”

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your [brand name/tier level]
deductible.)
[If the plan has a deductible
for all tiers, insert the
following two bullets.]

coverage limit]. Then you
move to payment stage 3,
Coverage Gap.

were $[insert year-to-date
TrOOP] (see Section 3).

20

• You begin in this payment
stage when you fill your first
prescription of the year.
During this stage, you (or
others on your behalf) pay
the full cost of your drugs.
• You generally stay in this
stage until you have paid
$[insert deductible amount]
for your drugs ($[insert
deductible amount] is the
amount of your deductible).
Then you move to payment
stage 2, Initial Coverage.

What happens next?
Once you (or others on your
behalf) have paid an
additional $[insert amount
needed in additional
TrOOP to meet the TrOOP
limit] in “out-of-pocket
costs,” you move to the next
payment stage (stage 4,
Catastrophic Coverage).

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21

[Use the following version of Section 2 for members without LIS who are in catastrophic coverage]

SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible
[If the plan has no
deductible, replace the text
in this cell with: (Because
there is no deductible for
the plan, this payment
stage does not apply to
you.)]
[If the plan has a brandname/tier level deductible,
insert the following two
bullets.]
• During this payment stage,
you (or others on your
behalf) pay the full cost of
your [brand-name/tier
level] drugs.
• You generally pay the full
cost of your [brandname/tier level] drugs until
you (or others on your
behalf) have paid $[insert
deductible amount] for
your [brand-name/tier
CMS-10141

STAGE 2
Initial Coverage

STAGE 3

STAGE 4

Coverage Gap

Catastrophic Coverage

• [Insert either: You begin in
this payment stage when
you fill your first
prescription of the year.
During this OR During this
payment] stage, the plan
pays its share of the cost of
your [insert if applicable:
generic/ tier levels] drugs
and you (or others on your
behalf) pay your share of
the cost.

• During this payment stage,
you (or others on your
behalf) receive a 70%
manufacturer’s discount on
covered brand name drugs
and the plan will cover
[insert if additional brand
gap coverage: “at least”]
another 5%, so you will pay
[insert if additional brand
gap coverage: “less than”]
25% of the negotiated price
on brand-name drugs. In
addition you pay [insert if
additional generic gap
coverage: “less than”] 25%
of the costs of generic
drugs.

• During this payment stage, the
plan pays most of the cost for
your covered drugs.

• [Insert if applicable: After
you (or others on your
behalf) have met your
[brand-name/tier level]
deductible, the plan pays its
share of the cost of your
[brand-name/tier level]
drugs and you (or others on
your behalf) pay your share
of the cost.]
• You generally stay in this
stage until the amount of
your year-to-date “total

• [When applicable, plans must
insert a brief explanation of what
the member pays during this
stage. For example: “For each
prescription, you pay whichever
of these is larger: a payment
equal to 5% of the cost of the
drug (this is called
“coinsurance”), or a copayment
($3.95 for a generic drug or a
drug that is treated like a generic,
$9.85 for all other drugs).”].

• You generally stay in this
stage until the amount of
your year-to-date “out-ofpocket costs” reaches
$7,050. Then you move to
payment stage 4,
Catastrophic Coverage.
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22

level] drugs ($[insert
deductible amount] is the
amount of your [brand
name/tier level]
deductible.)

drug costs” reaches $[insert
initial coverage limit].
Then you move to payment
stage 3, Coverage Gap.

[If the plan has a
deductible for all tiers,
insert the following two
bullets.]
• You begin in this payment
stage when you fill your
first prescription of the
year. During this stage, you
(or others on your behalf)
pay the full cost of your
drugs.
• You generally stay in this
stage until you have paid
$[insert deductible amount]
for your drugs ($[insert
deductible amount] is the
amount of your deductible).
Then you move to payment
stage 2, Initial Coverage.

What happens next?
You generally stay in this
payment stage, Catastrophic
Coverage, for the rest of the
calendar year (through December
31, 2022).

CMS-10141

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Use the following version of Section 2 for members with partial LIS who are in the yearly deductible stage]

23

SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible

STAGE 2
Initial Coverage

[If the plan has a deductible for all tiers,
insert the following three bullets.]

• During this payment
stage, the plan pays its
share of the cost of your
[insert if applicable:
generic/tier levels]
drugs and you (or others
on your behalf,
including “Extra Help”
from Medicare) pay
your share of the cost.

• You begin in this payment stage when
you fill your first prescription of the
year. During this stage, you (or others
on your behalf) pay the full cost of
your drugs.
• You generally stay in this stage until
you (or others on your behalf) have
paid $[insert appropriate deductible
amount for member with partial LIS]
for your drugs. [Only insert if
deductible is more than the partial
subsidy deductible limit: (The plan
deductible is usually $[insert usual plan
deductible], but you pay $ [insert
appropriate deductible amount for
member with partial LIS] because you
are receiving “Extra Help” from
Medicare.)]
• As of [insert end date of month] you
have paid $[insert year-to-date Total
Drug Costs] for your drugs.
CMS-10141

STAGE 3
Coverage Gap
(Because you are
receiving “Extra Help”
from Medicare, this
payment stage does not
apply to you.)

STAGE 4
Catastrophic Coverage
• During this payment
stage, the plan pays most
of the cost for your
covered drugs.
• You generally stay in this
stage for the rest of the
calendar year (through
December 31, 2022).

• [Insert if applicable:
After you (or others on
your behalf) have met
your [brand-name/tier
level] deductible, the
plan pays its share of the
cost of your [brandname/tier level] drugs
and you (or others on
your behalf) pay your
share of the cost.]
• You generally stay in this
stage until the amount of
your year-to-date “outof-pocket costs” reaches
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24

[If the plan has a brand-name/tier level
deductible, insert the following three
bullets.]
• During this payment stage, you (or
others on your behalf) pay the full cost
of your [brand-name/tier level] drugs.
• You generally pay the full cost of your
[brand-name/tier level] drugs until you
(or others on your behalf) have paid
$[insert deductible amount] for your
[brand-name/tier level] drugs. $[insert
deductible amount] is the amount of
your [brand-name/tier level]
deductible. [Only insert if deductible is
more than the partial subsidy
deductible limit: (The plan deductible is
usually $[insert usual plan deductible],
but you pay $[insert appropriate
deductible amount for member with
partial LIS] because you are receiving
“Extra Help” from Medicare.)]
• As of [insert end date for the month]
you have paid $[insert year-to-date
Deductible Drug Costs] for your drugs
in the deductible.

$7,050. When this
happens, you move to
payment stage 4,
Catastrophic Coverage.
[If the plan has a brandname/tier level
deductible, insert the
following bullet.]
• As of [insert end date of
month] your year-to-date
“out-of-pocket costs”
were $[insert year-to-date
TrOOP]. (See definitions
in Section 3).

What happens next?
Once you (or others on your behalf) have
paid an additional $[insert additional
amount needed to satisfy the deductible]
for your drugs, you move to the next
payment stage (stage 2, Initial
Coverage).

CMS-10141

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25

[Use the following version of Section 2 for members with LIS who are in the initial coverage stage]

SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible
[If the plan has no
deductible, insert the
following text as a
replacement for the other
text in this cell: (Because
there is no deductible for
the plan, this payment
stage does not apply to
you.)]
[If the plan has a
deductible and the EOB is
for a member with full
LIS, insert the following
text as a replacement for
the other text in this cell:
(Because you are
receiving “Extra Help”
from Medicare, this
payment stage does not
apply to you.)]
[If the plan has a brandname/tier level deductible,

CMS-10141

STAGE 2
Initial Coverage
• [Insert either: You begin in this
payment stage when you fill your
first prescription of the year.
During this OR During this
payment] stage, the plan pays its
share of the cost of your [insert if
applicable: generic/tier levels]
drugs and you (or others on your
behalf, including “Extra Help”
from Medicare) pay your share of
the cost.

STAGE 3
Coverage Gap
(Because you are receiving
“Extra Help” from
Medicare, this payment
stage does not apply to you.)

STAGE 4
Catastrophic Coverage
• During this payment stage,
the plan pays [insert
either: most of the cost for
OR for all] your covered
drugs.
• You generally stay in this
stage for the rest of the
calendar year (through
December 31, 2022).

• [Insert if applicable: After you (or
others on your behalf) have met
your [brand-name/tier level]
deductible, the plan pays its share
of the cost of your [brand-name/tier
level] drugs and you (or others on
your behalf) pay your share of the
cost.]
• You generally stay in this stage
until the amount of your year-todate “out-of-pocket costs”
reaches $7,050. As of [insert end
date of month] your year-to-date
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insert the following two
bullets.]
• During this payment stage,
you (or others on your
behalf) pay the full cost of
your [brand-name/tier
level] drugs.

“out-of-pocket costs” were $[insert
year-to-date TrOOP] (see
definitions in Section 3).

26

• You generally pay the full
cost of your [brandname/tier level] drugs until
you (or others on your
behalf) have paid $[insert
deductible amount] for
your [brand-name/tier
level] drugs ($[insert
deductible amount] is the
amount of your [brand
name/tier level]
deductible.) [Only insert if
deductible is more than the
partial subsidy deductible
limit: (The plan deductible
is usually $[insert usual
plan deductible], but you
pay $ [insert appropriate
deductible amount for
member with partial LIS]
because you are receiving
“Extra Help” from
Medicare.)]
[If the plan has a
deductible for all tiers,
insert the following two
bullets.]
• You begin in this payment
stage when you fill your
first prescription of the
CMS-10141

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27

year. During this stage,
you (or others on your
behalf) pay the full cost of
your drugs.
• You generally stay in this
stage until you (or others
on your behalf) have paid
$[insert appropriate
deductible amount for
member with partial LIS]
for your drugs ($[insert
appropriate deductible
amount for member with
partial LIS] is the amount
of your deductible). Then
you move to payment stage
2, Initial Coverage.

What happens next?
Once you (or others on your
behalf) have paid an additional
$[insert amount needed in
additional TrOOP to meet the
TrOOP limit] in “out-of-pocket
costs” for your drugs, you move
to the next payment stage (stage
4, Catastrophic Coverage).

CMS-10141

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28

[Use the following version of Section 2 for members with LIS who are in catastrophic coverage]

SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.”
How much you pay for a covered Part D prescription depends on which payment stage
you are in when you fill it. During the calendar year, whether you move from one
payment stage to the next depends on how much is spent for your drugs.

You are in this stage:
STAGE 1
Yearly Deductible
[If the plan has no
deductible, insert the
following text as a
replacement for the other
text in this cell: (Because
there is no deductible for
the plan, this payment
stage does not apply to
you.)]
[If the plan has a
deductible and the EOB is
for a member with full
LIS, insert the following
text as a replacement for
the other text in this cell:
(Because you are
receiving “Extra Help”
from Medicare, this
payment stage does not
apply to you.)]
[If the plan has a brandname/tier level
deductible, insert the
following two bullets.]
CMS-10141

STAGE 2
Initial Coverage
• [Insert either: You begin
in this payment stage
when you fill your first
prescription of the year.
During this OR During
this payment] stage, the
plan pays its share of the
cost of your [insert if
applicable: generic/tier
levels] drugs and you (or
others on your behalf,
including “Extra Help”
from Medicare) pay your
share of the cost.

STAGE 4
Catastrophic Coverage

STAGE 3
Coverage Gap
(Because you are receiving
“Extra Help” from
Medicare, this payment
stage does not apply to
you.)

• During this payment stage, the plan
pays [insert either: most of the cost
for OR for all] your covered drugs.
• [When applicable, plans must insert
a brief explanation of what the
member pays during this stage. For
example: “For each prescription, you
pay up to $3.95 for a generic drug or
a drug that is treated like a generic,
and $9.85 for all other drugs. OR
you pay nothing.”].

• [Insert if applicable: After
you (or others on your
behalf) have met your
[brand-name/tier level]
deductible, the plan pays
its share of the cost of your
[brand-name/tier level]
drugs and you (or others on
your behalf) pay your share
of the cost.]
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29

• During this payment stage,
you (or others on your
behalf) pay the full cost of
your [brand-name/tier
level] drugs.
• You generally pay the full
cost of your [brandname/tier level] drugs
until you (or others on
your behalf) have paid
$[insert deductible
amount] for your [brandname/tier level] drugs
($[insert deductible
amount] is the amount of
your [brand name/tier
level] deductible.)

• You generally stay in this
stage until the amount of
your “out-of-pocket costs”
reaches $ 7,050. Then you
move to payment stage 4,
Catastrophic Coverage.

[If the plan has a
deductible for all tiers,
insert the following two
bullets.]
• You begin in this payment
stage when you fill your
first prescription of the
year. During this stage,
you (or others on your
behalf) pay the full cost of
your drugs.
• You generally stay in this
stage until you (or others
on your behalf) have paid
$[insert appropriate
deductible amount for
member with partial LIS]
for your drugs ($[insert
appropriate deductible
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30

amount for member with
partial LIS] is the amount
of your deductible). Then
you move to payment
stage 2, Initial Coverage.

What happens next?
When you are in this payment stage,
Catastrophic Coverage, you generally
stay in it for the rest of the calendar
year (through December 31, 2022)

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V.

Model language for Section 3

31

[Note to plans: For an example of this page that shows formatting of the totals, see Exhibit D in the Appendix.]

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”

$[insert TrOOP for month] month of [insert name of
month], [insert year]

$[insert Total Drug Costs for month,] month of [insert name
of month], [insert year]

$[insert year-to-date TrOOP] year-to-date (since [insert
January, [year] or other date if applicable])

$[insert year-to-date Total Drug Costs] year-to-date (since
[insert January, [year] or other date if applicable])

[If applicable, insert the following text in every EOB after the
inclusion of the prior plan’s balance transfer: “(This total
includes $[insert the TrOOP balance transferred from prior
plan] in out-of-pocket costs from when you were in a different
plan earlier this year.)”]

[If applicable, insert the following text in every EOB after the
inclusion of the prior plan’s balance transfer: “(This total
includes $[insert the Total Drug Costs balance transferred
from prior plan] in total drug costs from when you were in a
different plan earlier this year.)”]

DEFINITION:

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.)

“Total drug costs” is the total of all payments made for
your covered Part D drugs. It includes:

•

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).

CMS-10141

•

What the plan pays.

•

What you pay.

•

What others (programs or organizations) pay for your
drugs.

[Insert only if the plan offers coverage of supplemental drugs
as part of an enhanced alternative benefit: NOTE: Our plan
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32

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), [insert if applicable: 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.]
•

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.]

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.

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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33

VI. Model language for Section 4
[Note to plans: For an example of this Section, see Exhibit E in the
Appendix.]

SECTION 4. Updates to the plan’s Drug List
that affect drugs you take
•

•

•

[Use this section to give formulary updates that affect drugs
the member is taking, i.e., any plan-covered drugs for which
the member filled a prescription during the current calendar
year while a member of the plan. Include updates only if
they affect drugs the member is taking. (Changes to the
formulary from one year to the next are announced in the
ANOC and do not need to be included in the EOB.) This
would include covered Part D drugs and supplemental
drugs listed in Charts 1 and 2 of Section 1, but not items
that would be covered for a beneficiary in original
Medicare under Parts A and/or B; for an enrollee in a Part
C plan under the plan’s Part A/B coverage; or otherwise
covered under non-Medicare insurance.]

website ([insert website URL]) is always the most current. Or call
[insert plan name] Member Services (phone numbers are on the
cover of this summary).
The Drug List tells which Part D prescription drugs are covered
by the plan. It also tells which of the [insert number of costsharing tiers] “cost-sharing tiers” each drug is in and whether
there are any restrictions on coverage for a drug.
During the year, following Medicare rules, we may make changes
to our Drug List. We may add new drugs, remove drugs, and add or
remove restrictions on coverage for drugs. We are also allowed to
change drugs from one cost-sharing tier to another.
•

o [Plans that otherwise meet the requirements to
immediately substitute generic drugs for brand name
drugs (or to increase tier sharing or add more
restrictions to access to brand name drugs) insert
the following bullet.] We may immediately replace a
brand name drug with a new generic that will appear
on the same or lower cost-sharing tier and with the
same or lower restrictions. Or we may immediately
add the new generic and add new restrictions to the
brand name drug or move it to a different-cost
sharing tier or both.

If there are no updates, insert the following as a
replacement for all of the text that follows in this section: At
this time, there are no new or upcoming changes to our
Drug List that will affect the coverage or cost of drugs you
take. (By “drugs you take,” we mean any plan-covered
drugs for which you filled prescriptions in [insert year] as a
member of our plan.)
If an update is for a negative formulary change that is not a
formulary maintenance change, insert: “If you are currently
taking this drug, this change will not affect your coverage
for this drug for the rest of the plan year.”]]

Some changes to the Drug List may happen immediately:

o We will immediately remove drugs from our Drug
List for safety reasons or when manufacturers
remove them from the market.
•

For all other changes to drugs you take, you will have at
least 30 days’ notice before any changes take effect.

About the Drug List and our updates

Updates that affect drugs you take

[Insert plan name] has a “List of Covered Drugs (Formulary)” or
“Drug List” for short. If you need a copy, the Drug List on our

The list that follows tells only about updates to the Drug List that
change the coverage or cost of drugs you take.

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(For purposes of this update list, “drugs you take” means any plancovered drugs for which you filled prescriptions in [insert year] as
a member of our plan.)
[Below we show model language for reporting several common
types of changes to the Drug List. Use it as applicable. Plans may
adapt this language as needed for grammatical consistency,
accuracy, and relevant detail (e.g., describing a drug as “brand
name” or “generic”). Plans may also provide additional
explanation of changes if desired, and suggest specific drugs that
might be suitable alternatives. To report changes for which model
language is not supplied, use the model language shown below as a
guide. Also, see the examples in Exhibit E in the Appendix.]

[Insert name of step therapy drug; plans may
also insert information about the strength or
form in which the drug is dispensed (e.g., tablets,
injectable, etc.)]
•

•

Date and type of change: Beginning [insert effective

date of the change], “step therapy” will be required for this
drug. This means you will be required to try [insert either: a
different drug first OR one or more other drugs first] before
we will cover [name of step therapy drug]. This requirement
encourages you to try another drug that is less costly, yet just
as safe and effective as [insert name of step therapy drug]. If
[insert either: this other drug does not OR the other drugs do
not] work for you, the plan will then cover [insert name of
step therapy drug].

Note: See the information later in this section that tells

“What you and your doctor can do.” [If applicable, plans may
insert information that identifies possible alternate drug(s).
For example, “(You and your doctor may want to consider
trying {alternate-drug-1} or {alternate drug-2}. Both are on
our Drug List and have no restrictions on coverage. They are
used in similar ways as [name of step therapy drug] and they
are on a lower cost-sharing tier.)”]

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[Insert name of quantity limits drug; plans may also
insert information about the strength or form in which
the drug is dispensed (e.g., tablets, injectable, etc.)]
•

Date and type of change: Beginning [insert effective

•

Note: See the information below that tells “What you and

date of the change], there will be a new limit on the amount
of the drug you can have: [insert description of how the
quantity will be limited].
your doctor can do.”

[Insert name of prior authorization drug; plans
may also insert information about the strength or
form in which the drug is dispensed (e.g., tablets,
injectable, etc.)]
•

Date and type of change: Beginning [insert effective

date of the change], “prior authorization” will be required for
this drug. This means you or your doctor need to get approval
from the plan before we will agree to cover the drug for you.
•

Note: See the information later in this section that tells

“What you and your doctor can do.” [Plans may insert
more explanation if desired, for example, “Your choices
include asking for prior authorization in order to
continue having this drug covered or changing to a
different drug.]

[The below language with appropriate modifications can be
used to provide notice of immediate generic substitutions by
Part D sponsors meeting the requirements, as well as other
generic changes as long as the notice is provided to the
enrollee within required timeframes.]

[Insert name of brand-name drug that has been
or will be replaced with generic or whose
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preferred or tiered cost-sharing or restrictions or
both changed (or will change) with the addition
of the new generic drug; plans may also insert
information about the strength or form in which
the drug is dispensed (e.g., tablets, injectable,
etc.)]
•

•

•

Date and type of change: Effective [insert effective

date of the change], the brand-name drug [insert name
of brand-name drug to be replaced with generic] [insert
either: “will be” OR “was”] [state if brand name drug is
being substituted or if there is a change to the brand
name drug’s cost-sharing tier or restrictions with the
addition of the generic drug or both. For instance,]
removed from our Drug List. We [insert either: “will
add” OR “added”] a new generic version of [insert
name of brand-name drug to be replaced with generic]
to the Drug List (it is called [insert name of replacement
generic drug]).
We are [insert either: “replacing” OR “replaced” [name
of brand name drug] OR [insert as applicable:
“changed” OR “are changing” “cost-sharing” OR
"restrictions” OR “cost-sharing and restrictions” for
[insert brand name drug] because [insert name of
generic drug], a [insert if applicable “new”] generic
version of [insert name of brand-name drug to be
replaced with generic], is now available. [Indicate tier
placement of generic drug. For instance, “[Insert name
of generic drug] (tier [insert cost-sharing tier number or
name for the replacement generic drug]) is on [insert
either: “the same” OR a “lower” cost-sharing tier than
[name of brand name drug], the drug it [insert either:
“is replacing” OR “replaced”] [insert if generic drug is
on a lower cost-sharing tier: (tier [insert cost-sharing
tier number or name for the brand name drug that is
being replaced.]) The amount you will pay for [insert

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•

name of generic drug] depends on which drug payment
stage you are in when you fill the prescription. To find
out how much you will pay for the [insert name of
generic drug], please call us at [insert plan name]
Member Services (our phone numbers and calling hours
are on the cover).
If your prescriber believes this generic drug is not right for
you due to your medical condition, you or your prescriber
can ask us to make an exception. See the information later
in this section that tells “What you and your doctor can
do.”

Note: [Plans may insert further information if applicable.

For example, “This change can save you money because
[insert name of replacement generic drug] (tier [insert costsharing tier number or name for the replacement generic
drug]) is in a lower cost-sharing tier than [insert name of
brand-name drug to be replaced with generic] (tier [insert
cost-sharing tier number or name for the replacement generic
drug]).”

[Insert name of drug for which cost-sharing will
increase; plans may also insert information
about the strength or form in which the drug is
dispensed (e.g., tablets, injectable, etc.)]
•

Date and type of change: Effective [insert effective
date of the change], [insert description of the change,
for example, “the brand-name drug [insert name of drug
for which cost-sharing will increase] will move from tier
2 to a higher cost-sharing tier (tier 3).”] The amount
you will pay for this drug depends on which drug
payment stage you are in when you fill the prescription.
To find out how much you will pay, please call us at
[insert plan name] Member Services (our phone
numbers and calling hours are on the cover).

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•

Note: See the information later in this section that tells

“What you and your doctor can do.” [Plans may add more
information if desired, for example, “(You and your doctor
may want to consider trying a lower cost generic drug,
[insert name of lower-cost generic drug], which is in costsharing tier [insert number or name of cost-sharing tier].)”

36

o (Section 6 of this monthly summary tells how to get
a copy of the Evidence of Coverage if you need it.
The Evidence of Coverage is also posted on our
website at .)

• What you and your doctor can do
Depending on the type of change, there may be different options to
consider. For example:
o Perhaps you can find a different drug covered by
the plan that might work just as well for you.
o You can call us at [insert plan name] Member
Services to ask for a list of covered drugs that treat
the same medical condition.
o This list can help your doctor to find a covered drug
that might work for you and have fewer restrictions
or a lower cost.
•

You and your doctor can ask the plan to make an
exception for you. This means asking us to agree that the

change in coverage or cost-sharing tier of a drug does not
apply to you.
o Your doctor will need to tell us why making an
exception is medically necessary for you.

o To learn what you must do to ask for an exception,
see the Evidence of Coverage [insert as applicable:]
that we sent to you OR [insert if plan/Part D sponsor
meets the conditions and is relying on notification of
electronic availability pursuant to 42 CFR §
423.2267] which is posted on our website at . [MA-PD plans insert: Look for
Chapter 9, What to do if you have a problem or
complaint.] [PDP plans insert: Look for Chapter 7,
What to do if you have a problem or complaint.]
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VII. Model language for Sections 5 and 6
[For an example of these sections, see Exhibit F in the Appendix]

SECTION 5. If you see mistakes on this
summary or have questions, what
should you do?
If you have questions, call us
If something is confusing or doesn’t look right on this monthly
prescription drug summary, please call us at [insert plan name]
Member Services (phone numbers are on the cover of this
summary). [If applicable:] You can also find answers to many
questions at our website: [insert plan website URL]
What about possible fraud?
Most health care professionals and organizations that provide
Medicare services are honest. Unfortunately, there may be some
who are dishonest.
If this monthly summary shows drugs you’re not taking, or
anything else that looks suspicious to you, please contact us.
•

Call us at [insert plan name] Member Services (phone
numbers are on the cover of this summary).

• Or, call Medicare at 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048. You can call these
numbers for free, 24 hours a day, 7 days a week.

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SECTION 6. Important things to know about
your drug coverage and your
rights
Your “Evidence of Coverage” [has OR if EOB is for
a member with LIS, insert “and LIS Rider” have]
the details about your drug coverage and costs
The Evidence of Coverage 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. [If EOB is for a member with
LIS, insert: Your LIS Rider (“Evidence of Coverage Rider for
People Who Get Extra Help Paying for their Prescriptions”) is a
short separate document that tells what you pay for your
prescriptions.]
We have sent you a copy of the Evidence of Coverage [if EOB is
for a member with LIS, insert: and LIS Rider]. These documents are
also available on our website: [insert plan website URL]. You may
also elect to receive the Evidence of Coverage electronically, please
contact us if you would like to change your method of delivery. If
you need another copy of either of these, please call us [insert plan
name] Member Services (phone numbers are on the cover of this
summary).
If you need another copy [if EOB is for a member with LIS, insert:
of either of these], please call us (phone numbers are on the cover
of this summary).
Remember, to get your drug coverage under our plan you must use
pharmacies in our network, except in certain circumstances. Also,
quantity limitations and restrictions may apply.

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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:
• [MA-PD insert: Chapter 7.] [PDP insert: Chapter 5.]
Asking the plan to pay its share of a bill you have received
for covered services or drugs.
• [MA-PD insert: Chapter 9.] [PDP insert: Chapter 7.] 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
[MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the
Evidence of Coverage).
• 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.
Please ask for help if you need it. Here’s how:
• You can call us at [insert plan name] Member Services
(phone numbers are on the cover of this monthly summary).

organization are in Chapter 2, Section 3 of your Evidence of
Coverage.

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 [insert appropriate section
number] of your Medicare & You [insert year] handbook or
call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048. You can call these numbers for
free, 24 hours a day, 7 days a week. 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 1800-325-0778. 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 Evidence of Coverage.

• You can call Medicare at 1-800-MEDICARE (1-800-6334227). TTY users should call 1-877-486-2048. You can call
these numbers for free, 24 hours a day, 7 days a week.
• You can call your State Health Insurance Assistance
Program (SHIP). The name and phone numbers for this
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39

This appendix contains examples of the Part D EOB. Since this Appendix
provides examples rather than model language, it does not follow the
conventions for showing model language (e.g., no text in blue).
The Exhibits in the appendix are listed below:
EXHIBIT A. Example of a cover page
EXHIBIT B. Examples that show different versions of Section 1 (the list of prescriptions)
EXHIBIT C. Examples that show different versions of Section 2 (drug payment stages)
EXHIBIT D. Example of Section 3 (amounts and definitions for TrOOP and total drug costs)
EXHIBIT E. Example of Section 4 (changes to the formulary)
EXHIBIT F. Example of Sections 5 and 6 (information for reference)
EXHIBIT G. Example of a Part D EOB (all sections included)
NOTE: Each exhibit is provided as a separate document.

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unless it displays a valid OMB control number. The valid OMB control number for this collection is 0938-0964. If you have any suggestions for
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40

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.

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