CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the For

2022 Part D EOB Exhibit E

EXHIBIT E. Example of Section 4 (changes to the formulary)
The pages that follow show an example of Section 4 in the model Part D EOB. Section
4 gives updates to the formulary.
This example is for a fictional MA-PD plan called “Birchwood Medicare Plus.” The
Part D sponsor has met all requirements and has the option to immediately replace
brand name drugs with their generic equivalents. The example has been designed to
illustrate model language for six different types of changes. It uses placeholders for the
names of the drugs. To help show how this section would look in an actual Part D
EOB, the example includes fictional information for the rest of the drug-related text.
To help members scan quickly through the list, the drug names are accented with
boxes.
To minimize burden on the readers and keep a consistent layout, the model Part D
EOB maintains a landscape orientation (the cover is the only exception; it can be
formatted either in landscape or portrait). To keep line lengths short enough to be easy
to read, pages in landscape orientation generally use two columns. As shown in the
example that follows, for Section 4 these two columns are of equal size.

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2022 Part D EOB Exhibit E

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

Updates that affect drugs you take

About the Drug List and our updates

(For purposes of this update list, “drugs you take” means any plancovered drugs for which you filled prescriptions in 2022 as a
member of our plan.)

Birchwood Medicare Plus has a “List of Covered Drugs
(Formulary)” – or “Drug List” for short. If you need a copy, the
Drug List on our website (http://www.birchwood.com) is always
the most current. Or call Birchwood Member Services (phone
numbers are on the cover of this summary).

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

The Drug List tells which Part D prescription drugs are covered
by the plan. It also tells which of the four “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.

•

Some changes to the Drug List may happen immediately:
o 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.
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 that you take, you will have
at least 30 days’ notice before any changes take effect.

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•

{Drug-name-A}
•

•

Date and type of change: Beginning June 1, 2022 “step

therapy” will be required for this drug. This means you will
be required to try a different drug first before we will cover
{Drug-name-A}. This requirement encourages you to try
another drug that is less costly, yet just as safe and effective
as {Drug-name-A}. If this other drug does not work for you,
the plan will then cover {Drug-name-A}.

Note: See the information later in this section that tells

“What you and your doctor can do.” (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 {Drug-nameA} and they are in a lower cost-sharing tier.)

•

Date and type of change: Effective June 1, 2022, the

•

Note: We replaced {Brand-name-D} because {Generic-

•

Date and type of change: Beginning October 1, 2022

there will be a new limit on the amount of the drug you can
have: no more than 60 tablets (extended release 80 mg
tablets) for a 30 day supply will be covered.

•

your doctor can do.”

Date and type of change: Beginning June 1, 2022,

“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.

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brand-name drug {Brand-name-D} was removed from our
Drug List. We added a new generic version of {Brand-nameD} to the Drug List (it is called {Generic-Drug-D}).

Drug-D}, a new generic version of {Brand-name-D}, is now
available. This change can save you money because
{Generic-Drug-D} (tier 1) is in a lower cost-sharing tier than
{Brand-name-D} (tier 3). The amount you will pay for
{Generic-Drug-D} depends on which drug payment stage
you are in when you fill the prescription. To find out how
much you will pay for {Generic-Drug-D}, please call us at
Birchwood Member Services (our phone numbers and
calling hours are on the cover).

Note: 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: See the information below that tells “What you and
{Drug-name-C}

•

your doctor can do.” Your choices include asking for prior
authorization in order to continue having this drug be
covered for you, or changing to a different drug.

{Brand-name-D}

{Drug-name-B}
•

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

{Brand-name-E}
•

Date and type of change: Effective July 1, 2022, the

brand-name drug {Brand-name-E} 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
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will pay, please call us at Birchwood Member Services (our
phone numbers are on the cover).
•

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

your doctor can do.” (You and your doctor may want to
consider trying a lower cost generic drug, {Alternategeneric-1}, which is in cost-sharing tier 1.)

{Brand-name-F}
•

•

Date and type of change: Effective October 1, 2022, the

brand-name drug {Brand-name-F} will be removed from our
Drug List. If you are currently taking this drug, this change
will not affect your coverage for this drug for the rest of the
plan year. We will add {Brand-name-G} to our Drug List,
which is less costly, yet just as safe and effective as {Brandname-F}.

Note: See the information below that tells “What you and
your doctor can do.”

What you and your doctor can do
Depending on the type of change, there may be different options to
consider. For example:

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• 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 Birchwood 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 that we sent to you or
is posted on our website at . Look for Chapter 7, What to do if you
have a problem or complaint.
o (Section 6 of this monthly summary tells how to
get a copy of the Evidence of Coverage if you
need one.)

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OMB Approval No. 0938-0964 (Expires 11/30/2021)