3 - Crosswalk for EOB and Exhibits

2020 (old version)

2022 (new version)

Type of
Change

Reason for change

Burden
Change

Throughout

Throughout: Updated contract year from
2020 to 2022.

Rev

Accuracy

No

Part I. General Instructions for
Plans

Updated instructions to include the
regulatory citation, 42 CFR § 423.128(e),
and associated requirements for
information concerning negotiated
pricing increases and lower cost
therapeutic alternatives.

Rev

Consistency with
4180-F regulatory
requirements

No

Part II. Model Language for the
Cover Page and Part VI. Model
Language for Section 4.

Update applicable references to the
Medicare Communications and
Marketing Guidelines to 42 CFR §
423.2267.

Rev

Consistent with
4190-F2 regulatory
requirements

No

Part III. Model Language for
Section 1. Under “Section 1 Your
prescriptions during the past
month,” second bullet: “Please
look over this information about
your prescriptions to be sure it is
correct. If you have any questions
or think there is a mistake, Section
5 tells what you should do.”

“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.”

Rev

Clarity, accuracy

No

Model Part D EOB

2020 (old version)

2022 (new version)

Part III. Section 1.

Under “Section 1 Your prescriptions
during the past month,” added new bullet
“Drug Pricing Information (Drug Price &
Price Change)” to explain added
information to enrollee.
Added new column to Chart 1 “Drug
Price & Price Change” for the inclusion
of drug price changes. Added instructions
to chart where plans are to insert required
price changes and lower cost therapeutic
alternatives. Removed language that said
providing lower cost alternatives could
be optional.
Update benefit parameters to reflect
current values for:
• Yearly Deductible,
• Initial Coverage Limit,
• Out of Pocket Coverage Limit

Part III. Chart 1. “Your
prescriptions for covered Part D
drugs”

Part IV. Section 2 Which “drug
payment stage” are you in?
Throughout.

Part VI. Section 4. “Updates to the
plan’s drug list that affect drugs
your take.” Throughout.
Part VII. Section 6. “Important
things to know about your drug
coverage and your rights”
Part D EOB Exhibits A-G
Throughout

Type of
Change
Add

Reason for change

Rev

Consistency with
4180-F regulatory
requirements

No

Rev

Accuracy

No

Where referring to changes in drug cost
sharing or restrictions, language was
added to indicate that one or both of
these changes could occur.
Updated references to include electronic
access to the plan’s EOC and instructions
for obtaining additional copies of EOB
and LIS rider, as applicable.

Rev

Completeness

No

Add

Completeness

No

Updated example contract year from
2020 to 2022

Rev

Accuracy

No

Consistency with
4180-F regulatory
requirements

Burden
Change
No

2020 (old version)

2022 (new version)

Throughout

Updated examples consistent with the
changes to the EOB detailed above.

Type of
Change
Rev

Reason for change
Accuracy

Burden
Change
No