CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Presc

Medicare Prescription Drug Benefit Program (CMS-10141)

Attachment 3c. CY 2022 EOB Exhibit B

Medicare Prescription Drug Benefit Program (Plans)

OMB: 0938-0964

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0964 can be found here:

2023-02-22 - Revision of a currently approved collection

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2022 Part D EOB Exhibit B

Exhibit B. Examples that show different versions of Section 1 (the list of
prescriptions)
NOTE: The examples in this exhibit have been designed to illustrate some of the main variations in
model language for Section 1 of the model Part D Explanation of Benefits (EOB). This section shows
the list of prescriptions filled by a plan member.
These examples of Section 1 use numbers for the year 2022 and placeholders for the names of drugs.
To help show how Section 1 would look in an actual Part D EOB, the examples include fictional
information for the rest of the prescription-related text.
PART 1........................................................................................................................................................................................................ 2
Examples 1-2: variations in text at end of Chart 1 that explain the totals .................................................................................................. 2
[Example 1: Deductible payment stage, no payments from plan or others]............................................................................................ 3
[Example 2: Initial coverage stage, payments from plan, from Extra Help, and from another organization]........................................ 5
PART 2........................................................................................................................................................................................................ 9
[Example 3: Using a separate chart for Supplemental Drug Coverage]................................................................................................ 10
PART 3...................................................................................................................................................................................................... 11
Example 4: Using “notes” on Chart 1 to show changes to the formulary ................................................................................................. 11
[Example 4: Excerpt from Chart 1 showing notes about changes to the formulary] ............................................................................ 12

2022 Part D EOB Exhibit B

PART 1.
Examples 1-2: variations in text at end of Chart 1 that explain the totals
Examples 1 and 2 are designed to illustrate differences in the wording of the text that explains the
total amounts which appear at the bottom of the Chart 1 list of prescriptions. These examples are for
plan members who have no supplemental drug coverage. Each is in a different payment stage:
•

Example 1 shows a version of Section 1 for a plan member who is in the deductible payment
stage. This member receives no payments from the plan or from third parties.

•

Example 2 shows a version of Section 1 for a plan member who is in the initial coverage
period. This member receives payments from the plan, from the Extra Help program (these
payments count toward out-of-pocket costs), and from Worker’s Compensation (these
payments do not count toward out-of-pocket costs).

2022 Part D EOB Exhibit B

[Example 1: Deductible payment stage, no payments from plan or others]

SECTION 1. Your prescriptions during the past month
•

Chart 1 shows your prescriptions for covered Part D drugs for the past month.

•

Please look over this information about your prescriptions and check to see that it’s
correct. If you have any questions or there’s 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
March 2022

{insert name of first drug} 40 mg tabs
03/09/22, ABC Pharmacy
Rx# 106663421555, 30 day supply
Lower Cost Therapeutic Alternative(s):
{insert name of second drug} 25 mg caps
03/09/22, ABC Pharmacy
Rx# 349000711222, 30 day supply
Lower Cost Therapeutic Alternative(s):

Plan paid

You paid

Other
payments

Drug Price &
Price Change

(made by
programs or
organizations;
see Section 3)

$0.00

$45.18

$0.00

$45.18
+4%

$1.20

$13.80

$0.00

$15.00
-3.5%

2022 Part D EOB Exhibit B

4
(continued)

CHART 1.
Your prescriptions for covered Part D drugs
March 2022

Plan paid

You paid

Other
payments

Drug Price &
Price Change

$0.00
(total for the
month)

Not Applicable

(made by
programs or
organizations;
see Section 3)

TOTALS for the month of March 2022:
Your “out-of-pocket costs” amount is $58.98. (This is
the amount you paid this month ($58.98) plus the
amount of “other payments” made this month that count
toward your “out-of-pocket costs” ($0.00). See
definitions in Section 3.)
Your “total drug costs” amount is $58.98. (This is the
total for this month of all payments made for your drugs
by the plan ($0.00) and you ($58.98) plus “other
payments” ($0.00).)

$0.00
(total for the
month)

$58.98
(total for the
month)

Plan paid

You paid

Other payments (made by programs

$0.00
(year-to-date
total)

$58.98
(year-to-date
total)

$0.00
(year-to-date total)

Year-to-date totals

or organizations; see Section 3)

1/1/22 through 3/31/22
Your year-to-date amount for “out-of-pocket costs”
is $58.98.
Your year-to-date amount for “total drug costs” is
$58.98.
For more about “out-of-pocket costs” and “total drug
costs,” see Section 3.

2022 Part D EOB Exhibit B

[Example 2: Initial coverage stage, payments from plan, from Extra Help, and from another organization]

SECTION 1. Your prescriptions during the past month
•

Chart 1 shows your prescriptions for covered Part D drugs for the past month.

•

Please look over this information about your prescriptions and check to see that it’s
correct. If you have any questions or think there’s a mistake, Section 5 shows you what to do.

•

CHART 1.
Your prescriptions for covered Part D drugs
March 2022

{insert name of first drug} inj 100 u/ml
03/09/22, ABC Pharmacy
Rx# 124868934511, 15 day supply
Lower Cost Therapeutic Alternative(s):

Plan paid

You paid

Other
payments

(made by
programs or
organizations; see
Section 3)

$107.11

$21.42

$14.28
(paid by
“Extra Help”)

Drug Price
& Price
Change

$142.81
+3.0%

2022 Part D EOB Exhibit B

CHART 1.
Your prescriptions for covered Part D drugs
March 2022

{insert name of second drug} 240 mg caps
03/12/22, ABC Pharmacy
Rx# 316582122880, 30 day supply
Lower Cost Therapeutic Alternative(s):

{insert name of third drug} 150 mg tabs
03/15/22, ABC Pharmacy
Rx# 632005552144, 30 day supply
Lower Cost Therapeutic Alternative(s):

Plan paid

You paid

Other
payments

Drug Price
& Price
Change

(made by
programs or
organizations; see
Section 3)

$6.60

$1.32

$2.26
(paid by
“Extra Help”)

$10.18
-1.1%

$326.90

$10.00

$43.59
(paid by “Extra
Help”)

$445.87
-8.4%

$65.38
(paid by Worker’s
Compensation)
{insert name of fourth drug} 50 mg tabs
03/15/22, ABC Pharmacy
Rx# 529042917765, 30 day supply
Lower Cost Therapeutic Alternative(s):
NOTE: Beginning on June 1, 2022, step therapy will be
required for this drug. See Section 4 for details.

$60.17

$12.03

$8.02
(paid by “Extra
Help”)

$80.22
+1.1%

2022 Part D EOB Exhibit B

CHART 1.
Your prescriptions for covered Part D drugs
March 2022

{insert name of first drug} 100 u/ml
03/15/22, ABC Pharmacy
Rx# 124868900912, 15 day supply
Lower Cost Therapeutic Alternative(s):
TOTALS for the month of March 2022:
Your “out-of-pocket costs” amount is $148.62. (This
is the amount you paid this month ($66.19) plus the
amount of “other payments” made this month that count
toward your “out-of-pocket costs” ($82.43). See
definitions in Section 3.)
Your “total drug costs” amount is $821.89. (This is
the total for this month of all payments made for your
drugs by the plan ($607.89) and you ($66.19) plus
“other payments” ($147.81).)

Plan paid

You paid

Other
payments

Drug Price
& Price
Change

(made by
programs or
organizations; see
Section 3)

$107.11

$21.42

$14.28
(paid by “Extra
Help”)

$142.81
+11.2%

$607.89
(total for the
month)

$66.19
(total for the
month)

$147.81
(total for the
month)

Not applicable

(Of this amount,
$82.43 counts
toward your “outof-pocket costs.”
See definitions in
Section 3.)

(continued)

2022 Part D EOB Exhibit B

Plan paid

You paid

$1,314.70

$445.20

$376.36

(year-to-date total)

Year-to-date totals as of 3/31/2022
Your year-to-date amount for “out-of-pocket costs”
is $690.80.
Your year-to-date amount for “total drug costs” is
$2,136.26.
For more about “out-of-pocket costs” and “total drug
costs,” see Section 3.

Other payments

(made by programs or
organizations; see
Section 3)

(Of this amount, $245.60
counts toward your “outof-pocket costs.” See
definitions in Section 3.)

2022 Part D EOB Exhibit B

PART 2.
[Example 3: Using a separate chart for Supplemental Drug Coverage]
Example 3 that follows shows a version of Chart 2, which is used to show prescriptions that are
covered under the plan’s Supplemental Drug Coverage. This chart follows Chart 1 (it comes
immediately after the summary of year-to-date totals).
Showing a separate chart for prescriptions covered under the plan’s Supplemental Drug
Coverage helps reduce potential confusion by emphasizing that payments for these prescriptions
do not count toward members’ out-of-pocket costs or total drug costs.
NOTE: When Chart 2 is included in an EOB, the following sentence is added to the first bulleted point in the introductory section of Chart
1: “(Prescriptions for drugs covered by our plan’s Supplemental Drug Coverage are shown separately in Chart 2).”

2022 Part D EOB Exhibit B

[Example 3: A separate chart (Chart 2) for prescriptions covered by Supplemental Drug Coverage]

CHART 2.
Your prescriptions for drugs covered by our
plan’s Supplemental Drug Coverage
March 2022
• This chart shows your prescriptions for drugs that are

Plan paid

You paid

03/01/22, ABC Pharmacy
Rx# 836725300111, 30 day supply

$2.80

$5.00

Totals for the month of March 2022

$2.80

$5.00

not generally covered by Medicare.

• These drugs are covered for you under our plan’s
Supplemental Drug Coverage.

Other payments

(made by programs or
organizations; see
Section 3)

{insert name of drug} 0.5 mg

$0.00

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.)

2022 Part D EOB Exhibit B

PART 3.
Example 4: Using “notes” on Chart 1 to show changes to the formulary
Example 4 shows how explanatory notes are used in Section 1. These notes
can provide 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 nonPart D drugs. The plan may also suggest lower-cost alternatives that a
member and his/her doctor might consider in this section.

2022 Part D EOB Exhibit B

[Example 4: Excerpt from Chart 1 showing notes about changes to the formulary]

SECTION 1. Your prescriptions during the past month
•

Chart 1 shows your prescriptions for covered Part D drugs for the past month.

•

Please look over this information about your prescriptions and check to see that it’s
correct. If you have any questions or think there’s a mistake, Section 5 shows you what to do.

•

CHART 1.

Your prescriptions for covered Part D drugs
March 2022

{insert name of first drug} 30 mg tabs
03/11/22, ABC Pharmacy
Rx# 222003740005, 30 day supply
Lower Cost Therapeutic Alternative(s):

Plan paid

You paid

Other
payments

Drug Price
& Price
Change

$0.00

$64.50

(made by
programs or
organizations; see
Section 3)

$48.29

$16.21

+1.3%

NOTE: Beginning on June 1, 2022, step therapy will
be required for this drug. See Section 4 for details.
{insert name of second drug} 50 mg caps
03/21/22, ABC Pharmacy

$72.34

$22.60

$0.00

$94.94

2022 Part D EOB Exhibit B

Rx# 671142913332, 30 day supply
Lower Cost Therapeutic Alternative(s):

-7.4%

NOTE: Beginning on June 1, 2022, step therapy will
be required for this drug. See Section 4 for details.
{insert name of third drug} 0.5 mg
03/25/22, ABC Pharmacy
Rx# 444025344660, 30 day supply
Lower Cost Therapeutic Alternative(s):

$2.80

$5.00

$0.00

NOTE: Effective June 1, 2022, this drug will be
moved from cost-sharing tier 2 to a higher costsharing tier (tier 3). See Section 4 for details.
{NOTE: This example shows only the first part of Chart 1. The rest of the chart is not included.}

$7.80
-2.1%

File Type	application/pdf
File Title	CY 2022 Exhibit B
Author	CMS-MDBG-DPDP
File Modified	2021-06-23
File Created	2021-06-21