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

2022 Part D EOB Exhibit D

Exhibit D. Example of Section 3 (amounts and definitions for TrOOP
and total drug costs) for a plan that offers Supplemental
Drug Coverage
NOTE: The page that follows has a fictional example of Section 3 from the model Part
D EOB; it is for a fictional plan that offers Supplemental Drug Coverage. Using
numbers from 2022 for illustration, this section gives amounts and definitions of outof-pocket costs and total drug costs.
The main purpose of Section 3 is to give the definitions. The monthly and year-to-date
totals for a member’s out-of-pocket costs and total drug costs have already been given
at the end of Chart 1 in Section 1 (Section 1 is the list of prescriptions filled during the
month).

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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.

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Your “out-of-pocket costs”

Your “total drug costs”

$310.60

$453.84

month of September, 2022

month of September, 2022

$4,356.00 year-to-date (since January 2022) (This total includes $312.50 in outof-pocket costs from when you were in a different plan earlier this year.)

$6,244.34 year-to-date (since January 2022)
(This total includes $600.50 in total drug costs from
when you were in a different plan earlier this year.)

DEFINITION:

DEFINITION:

“Out of pocket costs” includes:

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

•

•

What you pay when you fill or refill a prescription for a covered Part D

drug. (This includes payments for your drugs, if any, that are made by
family or friends.)

Payments made for your drugs by any of the following programs or
organizations: “Extra Help” from Medicare, Medicare’s Coverage Gap
Discount Program; Indian Health Service; AIDS drug assistance programs;
most charities, and most State Pharmaceutical Assistance Programs (SPAPs).

It does not include:
•

Payments made for: a) plan premiums, b) drugs not covered by our plan; c)
non-Part D drugs (such as drugs you receive during a hospital stay); d)
drugs covered by our plan’s Supplemental Drug Coverage; e) drugs
obtained at a non-network pharmacy that does not meet our out-of-network
pharmacy access policy.

•

Payments made for your drugs by any of the following programs or
organizations: employer or union health plans; some government-funded
programs, including TRICARE and Veteran’s Administration; Worker’s
Compensation, and some other programs.

•

What the plan pays.

•

What you pay.

•

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

NOTE: Our plan offers Supplemental Drug

Coverage for some drugs not generally covered by
Medicare. If you have filled any prescriptions for
these drugs this month, they are listed in a separate
chart (Chart 2) in Section 1. The amounts paid for
these drugs do not count toward your out-of-pocket
costs or total drug costs.

Learn more. Medicare has made the rules about which types of payments count and do not count
toward “out-of-pocket costs” and “total drug costs.” The definitions on this page give you only the main
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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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PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information 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 improving this
form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
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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