Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

[Insert 2024 plan name] Annual Notice of Changes for 2024

1

[Cost plan models]
[2024 ANOC model]

[Insert 2024 plan name] ([insert plan type]) offered by [insert
cost plan name] [insert DBA names in parentheses, as
applicable, after listing required cost plan names]

Annual Notice of Changes for 2024
[Optional: insert member name]
[Optional: insert member address]
You are currently enrolled as a member of [insert 2023 plan name]. Next year, there will be
changes to the plan’s costs and benefits. Please see page 4 for a Summary of Important Costs,
including Premium.
This document tells about the changes to your plan. To get more information about costs,
benefits, or rules please review the Evidence of Coverage, which is located on our website at
[insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR
separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You
may also call Member Services to ask us to mail you an Evidence of Coverage.)
•

If you wish to enroll in a Medicare Advantage health plan or Medicare prescription
drug plan, you have from October 15 until December 7 to make changes to your
Medicare coverage for next year. If you decide other cost plan coverage better meets
your needs, you can switch cost plans anytime the cost plan is accepting members.
You may also change to Original Medicare. For more information see Section 4.2 of
this document.

What to do now
1. ASK: Which changes apply to you

 Check the changes to our benefits and costs to see if they affect you.
•

Review the changes to Medical care costs (doctor, hospital).

•

[Insert if offering Part D] Review the changes to our drug coverage, including
authorization requirements and costs.

•

Think about how much you will spend on premiums, deductibles, and cost sharing.

[Plans that offer Part D, insert as applicable:

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 Check the changes in the 2024 Drug List to make sure the drugs you currently take
are still covered.

 Check to see if your primary care doctors, specialists, hospitals, and other providers,
including pharmacies will be in our network next year.

 Think about whether you are happy with our plan.
2. COMPARE: Learn about other plan choices

 Check coverage and costs of plans in your area. Use the Medicare Plan Finder at
www.medicare.gov/plan-compare website or review the list in the back of your
Medicare & You 2024 handbook.

 Once you narrow your choice to a preferred plan, confirm your costs and coverage on
the plan’s website.

3. CHOOSE: Decide whether you want to change your plan
•

If you don't join another plan by December 7, 2023, you will stay in [insert plan name].

•

To change to a Medicare Advantage health plan or Medicare prescription drug plan, you
can switch plans between October 15 and December 7. Your new coverage will start on
January 1, 2024. This will end your enrollment with [insert plan name].

•

If you recently moved into, currently live in, or just moved out of an institution (like a
skilled nursing facility or long-term care hospital), you can switch plans or switch to
Original Medicare (either with or without a separate Medicare prescription drug plan) at
any time.

Additional Resources
•

[Plans that meet the 5% alternative language threshold insert: This document is
available for free in [insert languages that meet the 5% threshold].]

•

Please contact our Member Services number at [insert member services phone number]
for additional information. (TTY users should call [insert TTY number].) Hours are
[insert days and hours of operation]. This call is free.

•

[Plans must insert language about availability of alternate formats (e.g., braille, large
print, audio) as applicable.]

About [insert 2024 plan name]
•

[Insert Federal contracting statement.]

•

When this document says “we,” “us,” or “our,” it means [insert cost plan name] [insert
Plan/Part D sponsor in parentheses, as applicable, after listing required cost plan names
throughout this document]. When it says “plan” or “our plan,” it means [insert 2024 plan
name].

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[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID]]

Annual Notice of Changes for 2024
Table of Contents
[Update table below after completing edits.]
Summary of Important Costs for 2024 ....................................................................... 4
SECTION 1

We Are Changing the Plan’s Name .................................................. 7

SECTION 1

Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2024 plan name] in 2024 ............ 7

SECTION 2
Changes to Benefits and Costs for Next Year ................................. 8
Section 2.1 – Changes to the Monthly Premium ...................................................................... 8
Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount .......................................... 8
Section 2.3 – Changes to the Provider and Pharmacy Networks .............................................. 9
Section 2.4 – Changes to Benefits and Costs for Medical Services ....................................... 10
Section 2.5 – Changes to Part D Prescription Drug Coverage ............................................... 11
SECTION 3

Administrative Changes ................................................................. 17

SECTION 4
Deciding Which Plan to Choose ..................................................... 18
Section 4.1 – If you want to stay in [insert 2024 plan name] ................................................ 18
Section 4.2 – If you want to change plans .............................................................................. 19
SECTION 5

Deadline for Changing Plans .......................................................... 20

SECTION 6

Programs That Offer Free Counseling about Medicare ................ 20

SECTION 7

Programs That Help Pay for Prescription Drugs........................... 21

SECTION 8
Questions? ...................................................................................... 22
Section 8.1 – Getting Help from [insert 2024 plan name] ..................................................... 22
Section 8.2 – Getting Help from Medicare ............................................................................. 22

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Summary of Important Costs for 2024
The table below compares the 2023 costs and 2024 costs for [insert 2024 plan name] in
several important areas. Please note this is only a summary of costs.
[If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the
2023 Medicare amounts and must insert: These are 2023 cost-sharing amounts and may
change for 2024. [Insert plan name] will provide updated rates as soon as they are released.
Member cost-sharing amounts may not be left blank.]
Cost

2023 (this year)

2024 (next year)

Monthly plan premium*
[Insert 2023 premium
[Plans that offer Part D insert: Your amount]
premium may be higher [Plans with
$0 premium should not include: or
lower] than this amount.] See [edit
section number as needed] Section
2.1 for details.

[Insert 2024 premium
amount]

[Plans with no deductible may
delete this row.]
Deductible

[Insert 2024 deductible
amount]

[Insert 2023 deductible
amount]

[Insert 2023 MOOP
[Plans not offering MOOP may
amount]
delete this row.]
Maximum out-of-pocket amount
This is the most you will pay out-ofpocket for your covered [insert if
applicable: Part A and Part B]
services. (See [edit section number
as needed] Section 2.2 for details.)

[Insert 2024 MOOP
amount]

Doctor office visits

Primary care visits: [insert
2023 cost sharing for
PCPs] per visit
Specialist visits: [insert
2023 cost sharing for
specialists] per visit

Primary care visits: [insert
2024 cost sharing for
PCPs] per visit
Specialist visits: [insert
2024 cost sharing for
specialists] per visit

Inpatient hospital stays

[Insert 2023 cost sharing]

[Insert 2024 cost sharing]

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[Insert 2024 plan name] Annual Notice of Changes for 2024

Cost
[Plans that do not offer Part D
delete.]
Part D prescription drug coverage
(See [edit section number as
needed] Section 2.5 for details.)

5

2023 (this year)

2024 (next year)

Deductible: [Insert 2023
deductible amount] [If an
amount other than $0,
add: except for covered
insulin products and most
adult Part D vaccines.]
[Copayment/Coinsurance
as applicable] during the
Initial Coverage Stage:

Deductible: [Insert 2024
deductible amount] [If an
amount other than $0,
add: except for covered
insulin products and most
adult Part D vaccines.]
[Copayment/Coinsurance
as applicable] during the
Initial Coverage Stage:

Drug Tier 1: [Insert
2023 cost sharing]
[Insert if insulin cost
sharing differs from
cost sharing for other
drugs on the same
tier: You pay $[xx]
per month supply of
each covered insulin
product on this tier.]
• [Repeat for all drug
tiers.]
Catastrophic Coverage:

Drug Tier 1: [Insert
2024 cost sharing]
[Insert if insulin cost
sharing differs from
cost sharing for other
drugs on the same tier:
You pay $[xx] per
month supply of each
covered insulin
products on this tier.]
• [Repeat for all drug
tiers.]
Catastrophic Coverage:

•

•

•

•

•
During this payment
stage, the plan pays
most of the cost for
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
whichever of these is
larger: a payment
equal to 5% of the cost
of the drug (this is
called coinsurance),
or a copayment ($4.15
for a generic drug or a •
drug that is treated
like a generic, and

[Plans that do not
cover excluded drugs
under an enhanced
benefit, OR plans that
do cover excluded
drugs under an
enhanced benefit but
with the same cost
sharing as covered
Part D drugs in this
stage, insert the
following: During this
payment stage, the
plan pays the full cost
for your covered Part
D drugs. You pay
nothing.]
[Plans that cover
excluded drugs under
an enhanced benefit
with cost sharing in

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Cost

6

2023 (this year)
$10.35 for all other
drugs.)].

2024 (next year)

•

•

this stage, insert the
following 2 bullets:
During this payment
stage, the plan pays the
full cost for your
covered Part D drugs.
You may have cost
sharing for drugs that
are covered under our
enhanced benefit.]

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[If Section 1 does not apply, plans should omit it and renumber remaining sections as needed.]

SECTION 1 We Are Changing the Plan’s Name
[Plans that are changing the plan name, as approved by CMS, include Section 1, using the
section title above and the following text:
On January 1, 2024, our plan name will change from [insert 2023 plan name] to [insert 2024
plan name].
[Insert language to inform members if they will receive new ID cards and how, as well as if the
name change will impact any other member communication.]]

SECTION 1 Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2024 plan name] in 2024
[If the member is being enrolled into another plan due to a consolidation or due to a transition
from a D-SNP look-alike plan under 42 CFR 422.514, include Section 1, using the section title
above and the text below. It is additionally expected that, as applicable throughout the ANOC,
every plan/sponsor that cross walks a member from a non-renewed plan to a consolidated
renewal plan or transitions a member from a D-SNP look-alike plan to a renewal plan meeting
the criteria in 42 CFR 422.514(e) will compare benefits and costs, including cost sharing for
drug tiers, from that member’s previous plan to the consolidated plan or the renewal plan. Every
plan/sponsor that transitions a member from a D-SNP look-alike plan to a renewal plan, as
indicated above, is encouraged to include language about the transition in a cover letter that
accompanies the ANOC.]
On January 1, 2024, [insert cost plan name] [insert Plan/Part D sponsor in parentheses, as
applicable, after listing required cost plan names throughout this document] will be [insert as
applicable: combining [insert 2023 plan name] with one of our plans, [insert 2024 plan name]
or transitioning you from [insert 2023 D-SNP look-alike plan name] to [insert 2024 renewal
plan name]. The information in this document tells you about the differences between your
current benefits in [insert 2023 plan name] and the benefits you will have on January 1, 2024 as
a member of [insert 2024 plan name].]
If you do nothing by December 31, 2023, we will automatically enroll you in our [insert
2024 plan name]. You have choices about how to get your Medicare coverage. If you want to
change to a different cost plan you may do so anytime the cost plan is accepting members. If you
want to change plans, you can do so between October 15 and December 7. If you want to change
to Original Medicare, you may do so at any time. If you are eligible for “Extra Help,” you may
be able to change plans during other times.

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SECTION 2 Changes to Benefits and Costs for Next Year
Section 2.1 – Changes to the Monthly Premium
[Plans offering the following premiums must list separately in the table below: (1) Plan
premium; (2) optional supplemental benefit premiums (only plans offering optional supplemental
benefits during one or both of the comparison years); and (3) Part B premium reduction (only
plans with Part B premium reductions during one or both of the comparison years.]
Cost
Monthly premium
[If there are no changes from year to
year, plans may indicate in the
column that there is no change for the
upcoming benefit year. However, the
premium must also be listed.]

2023 (this year)

2024 (next year)

[Insert 2023 premium
amount]

[Insert 2024 premium
amount]

(You must also continue to pay your
Medicare Part B premium.)
[Plans that do not offer Part D: delete bulleted information below.]
•

Your monthly plan premium will be more if you are required to pay a lifetime Part D late
enrollment penalty for going without other drug coverage that is at least as good as
Medicare drug coverage (also referred to as creditable coverage) for 63 days or more.

•

If you have a higher income, you may have to pay an additional amount each month
directly to the government for your Medicare prescription drug coverage.

•

[Plans with $0 premium should not include this bullet] Your monthly premium will be
less if you are receiving “Extra Help” with your prescription drug costs. Please see
Section 7 regarding “Extra Help” from Medicare.

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount
[Plans that include the costs of supplemental benefits (e.g., POS benefits) in the MOOP limit
may revise this information as needed.]
[Plans not offering MOOP: delete this section and renumber remaining sections as needed.]
Medicare requires all health plans to limit how much you pay “out-of-pocket” for the year. This
limit is called the “maximum out-of-pocket amount.” Once you reach this amount, you generally
pay nothing for covered [insert if applicable: Part A and Part B] services for the rest of the year.
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Cost
Maximum out-of-pocket
amount
Your costs for covered medical
services (such as copays [insert
if plan has a deductible: and
deductibles]) count toward your
maximum out-of-pocket amount.
[Plans with no premium and/or
no Part D coverage may modify
or delete the following sentence
as needed.] Your plan premium
and your costs for prescription
drugs do not count toward your
maximum out-of-pocket amount.

9

2023 (this year)

2024 (next year)

[Insert 2023 MOOP
amount]

[Insert 2024 MOOP
amount]
Once you have paid [insert
2024 MOOP amount] outof-pocket for covered
[insert if applicable: Part
A and Part B] services,
you will pay nothing for
your covered [insert if
applicable: Part A and Part
B] services for the rest of
the calendar year.

[If there are no changes from
year to year, plans may indicate
in the column that there is no
change for the upcoming benefit
year. However, the premium
must also be listed.]

Section 2.3 – Changes to the Provider and Pharmacy Networks
[Insert if applicable: We included a copy of our current Provider and/or Pharmacy Directory in
the envelope with this document.] Updated directories are [Insert if applicable: also] located on
our website at [insert URL]. You may also call Member Services for updated provider and/or
pharmacy information or to ask us to mail you a directory, which we will mail within three
business days.
[Insert applicable section: For a plan that does not have changes in its provider network] There
are no changes to our network of providers for next year.
[Insert applicable section: For a plan that has changes in its provider network] There are
changes to our network of providers for next year. Please review the 2024 Provider Directory to
see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
[Insert applicable section: For a plan that does not have changes in its pharmacy network]
There are no changes to our network of pharmacies for next year.
[Insert applicable section: For a plan that has changes in its pharmacy network] There are
changes to our network of pharmacies for next year. Please review the 2024 Pharmacy
Directory to see which pharmacies are in our network.
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[All plans must insert the following] It is important that you know that we may make changes to
the hospitals, doctors and specialists (providers), and pharmacies that are part of your plan during
the year. If a mid-year change in our providers affects you, please contact Member Services so
we may assist.

Section 2.4 – Changes to Benefits and Costs for Medical Services
[If there are no changes in benefits or in cost sharing, revise heading to “There are no changes to
your benefits or amounts you pay for medical services” and replace the rest of this section with:
Our benefits and what you pay for these covered medical services will be exactly the same in
2024 as they are in 2023.]
We are making changes to costs and benefits for certain medical services next year. The
information below describes these changes.
[The table must include: (1) all new benefits that will be added or 2023 benefits that will end for
2024, including any new optional supplemental benefits (plans must indicate these optional
supplemental benefits are available for an extra premium); (2) new/changing limitations or
restrictions, including referrals, prior authorizations, and Part B step therapy, if applicable,
Original Medicare Part A/B benefits, Drug benefits, if applicable, and non-drug supplemental
benefits for CY2024; and (3) all changes in cost sharing for 2024 for covered medical services,
including any changes to service category out-of-pocket maximums and cost sharing for optional
supplemental benefits (plans must indicate these optional supplemental benefits are available for
an extra premium). Note that beginning July 2023, cost-sharing for insulin furnished through an
item of DME is subject to a coinsurance cap of $35 for one-month’s supply of insulin.]
[If using Medicare FFS amounts (e.g., Inpatient and SNF cost sharing) the plan must insert the
2023 Medicare amounts and must insert: These are 2023 cost-sharing amounts and may change
for 2024. [Insert plan name] will provide updated rates as soon as they are released. Member
cost-sharing amounts may not be left blank.]

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Cost
[Insert benefit name]

[Insert benefit name]

11

2023 (this year)

2024 (next year)

[For benefits that were not
covered in 2023 [insert benefit
name] is not covered.]

[For benefits that were not
covered in 2024 [insert benefit
name] is not covered.]

[For benefits with a copayment
insert:
You pay a $[insert 2023
copayment amount] copay
[insert language as needed to
accurately describe the benefit,
e.g., per office visit].]

[For benefits with a copayment
insert:
You pay a $[insert 2024
copayment amount] copay
[insert language as needed to
accurately describe the benefit,
e.g., per office visit].]

[For benefits with a
coinsurance insert:
You pay [insert 2023
coinsurance percentage] % of
the total cost

[For benefits with a
coinsurance insert:
You pay [insert 2024
coinsurance percentage] % of
the total cost

[insert language as needed to
accurately describe the benefit,
e.g., for up to one visit per
year].]

[insert language as needed to
accurately describe the benefit,
e.g., for up to one visit per
year].]

[Insert 2023 cost/coverage,
using format described above.]

[Insert 2024 cost/coverage,
using format described above.]

[Plans that do not offer Part D delete Section 2.5 below.]

Section 2.5 – Changes to Part D Prescription Drug Coverage
Changes to Our Drug List
Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is
[insert: in this envelope] OR [insert: provided electronically]. [If including an abridged
formulary, add the following language: The Drug List includes many – but not all – of the drugs
that we will cover next year. If you don’t see your drug on this list, it might still be covered. You
can get the complete Drug List by calling Member Services (see the back cover) or visiting our
website ([insert URL]).]
[Plans with no changes to covered drugs, tier assignment, or restrictions may replace the rest of
this section with: We have not made any changes to our Drug List for next year. However,
during the year, we might make other changes that are allowed by Medicare rules. We can also
immediately remove drugs considered unsafe by the Food and Drug Administration (FDA) or
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withdrawn from the market by a product manufacturer. We update our online Drug List to
provide the most up to date list of drugs.]
We made changes to our Drug List, including changes to the drugs we cover and changes to the
restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure
your drugs will be covered next year and to see if there will be any restrictions.
Most of the changes in the Drug List are new for the beginning of each year. However, during
the year, we might make other changes that are allowed by Medicare rules. For instance, we can
immediately remove drugs considered unsafe by the FDA or withdrawn from the market by a
product manufacturer. We update our online Drug List to provide the most up to date list of
drugs.
If you are affected by a change in drug coverage at the beginning of the year or during the year,
please review Chapter 9 of your Evidence of Coverage and talk to your doctor to find out your
options, such as asking for a temporary supply, applying for an exception and/or working to find
a new drug. You can also contact Member Services for more information.
[Plan sponsors implementing for the first time in 2024 have the option to immediately replace
brand name drugs with their new generic equivalents, that otherwise meet the requirements,
should insert the following: Starting in 2024, we may immediately remove a brand name drug on
our Drug List if, at the same time, we replace it with a new generic drug on the same or lower
cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic
drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a
different cost-sharing tier or add new restrictions or both.
This means, for instance, if you are taking a brand name drug that is being replaced or moved to
a higher cost-sharing tier, you will no longer always get notice of the change 30 days before we
make it or get a month’s supply of your brand name drug at a network pharmacy. If you are
taking the brand name drug, you will still get information on the specific change we made, but it
may arrive after the change is made.]
Changes to Prescription Drug Costs
[Plans that enroll partial dual eligible beneficiaries should delete the following paragraph for
QDWI beneficiaries.] Note: If you are in a program that helps pay for your drugs (“Extra Help”),
the information about costs for Part D prescription drugs [insert as applicable: may OR
does] not apply to you. [If not applicable, omit information about the LIS Rider.] We [insert as
appropriate: have included OR sent you] a separate insert, called the “Evidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the LowIncome Subsidy Rider or the LIS Rider), which tells you about your drug costs. If you receive
“Extra Help” [if plan sends LIS Rider with ANOC, insert: and didn’t receive this insert with this
packet,] [if plan sends LIS Rider separately from the ANOC, insert: and you haven’t received
this insert by [insert date],] please call Member Services and ask for the LIS Rider.

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There are four drug payment stages. The information below shows the changes to the first two
stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not
reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage.)
Changes to the Deductible Stage
Stage
Stage 1: Yearly Deductible Stage
During this stage, you pay the full cost
of your [insert as applicable: Part D
OR brand name OR [tier name(s)]]
drugs until you have reached the yearly
deductible. The deductible does not
apply to covered insulin products and
most adult Part D vaccines.

[Plans with no deductible, omit text
above.]

2023 (this year)

2024 (next year)

The deductible is
$[insert 2023
deductible].

The deductible is
$[insert 2024
deductible].

[Plans with no
deductible replace the
text above with: Because
we have no deductible,
this payment stage does
not apply to you.]

[Plans with no
deductible replace the
text above with: Because
we have no deductible,
this payment stage does
not apply to you.]

[Plans with tiers
excluded from the
deductible in 2023
and/or 2024 insert the
following:] During this
stage, you pay [insert
cost-sharing amount
that a member would
pay in a tier(s) that is
exempted from the
deductible] cost sharing
for drugs on [insert
name of tier(s) excluded
from the deductible] and
the full cost of drugs on
[insert name of tier(s)
where copayments
apply] until you have
reached the yearly
deductible.

[Plans with tiers
excluded from the
deductible in 2023
and/or 2024 insert the
following:] During this
stage, you pay [insert
cost-sharing amount
that a member would
pay in a tier(s) that is
exempted from the
deductible] cost sharing
for drugs on [insert
name of tier(s) excluded
from the deductible] and
the full cost of drugs on
[insert name of tier(s)
where copayments
apply] until you have
reached the yearly
deductible.

Changes to Your Cost Sharing in the Initial Coverage Stage
[Plans that are changing the cost sharing from coinsurance to copayment or vice versa from
2023 to 2024 insert: For drugs on [insert name of tier(s)], your cost sharing in the initial
coverage stage is changing from [insert whichever is appropriate: a copayment to coinsurance

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14

OR coinsurance to a copayment.] Please see the following chart for the changes from 2023 to
2024.]
[Plans must list all drug tiers in the table below and show costs for a one-month supply filled at
a network retail pharmacy. Plans that have pharmacies that provide preferred cost sharing must
provide information on both standard and preferred cost sharing using the second alternate
chart. Plans without drug tiers may revise the table as appropriate.]
Stage

2023 (this year)

2024 (next year)

Your cost for a one-month
[Plans that are changing
the number of days in their
one-month supply from
2023 to 2024 insert ([xx]day) rather than onemonth] supply filled at a
network pharmacy with
standard cost sharing:

Your cost for a one-month
[Plans that are changing
the number of days in their
one-month supply from
2023 to 2024 insert ([xx]day) rather than onemonth] supply filled at a
network pharmacy with
standard cost sharing:

[Insert name of Tier 1]:

[Insert name of Tier 1]:

You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost.]

You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost.] [Insert if
insulin cost sharing differs
from cost sharing for other
drugs on the same tier:
You pay $[xx] per month
supply of each covered
insulin product on this
tier.]

Stage 2: Initial Coverage Stage
[Plans with no deductible delete
the first sentence.] Once you pay
the yearly deductible, you move
to the Initial Coverage Stage.
During this stage, the plan pays
its share of the cost of your drugs,
and you pay your share of the
cost. [Plans that are changing the
cost sharing from a copayment to
coinsurance or vice versa from
2023 to 2024 insert for each
applicable tier: For 2023 you
paid [insert as appropriate: a
$[xx] copayment OR [xx]%
coinsurance] for drugs on [insert
tier name]. For 2024 you will pay
[insert as appropriate: a $[xx]
copayment OR [xx]%
coinsurance] for drugs on this
tier.”]
Most adult Part D vaccines are
covered at no cost to you.

[Insert name of Tier 2]:
You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost.]
[Repeat for all tiers]

[Insert name of Tier 2]:
You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost.] [Insert if
insulin cost sharing differs
from cost sharing for other
drugs on the same tier:
You pay $[xx] per month
supply of each covered
insulin product on this
tier.]
[Repeat for all tiers]

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Stage
Stage 2: Initial Coverage Stage
(continued)
The costs in this row are for a
one-month ([insert number of
days in a one-month supply]-day)
supply when you fill your
prescription at a network
pharmacy that provides standard
cost sharing. [Plans that are
changing the number of days in
their one-month supply from 2023
to 2024 insert: The number of
days in a one-month supply has
changed from 2023 to 2024 as
noted in the chart.] For
information about the costs
[insert as applicable: for a longterm supply, at a network
pharmacy that offers preferred
cost sharing, or for mail-order
prescriptions], look in Chapter 6,
Section 5 of your Evidence of
Coverage.
[Insert if applicable: We changed
the tier for some of the drugs on
our Drug List. To see if your
drugs will be in a different tier,
look them up on the Drug List.]

15

2023 (this year)

2024 (next year)

Once [insert as applicable:
your total drug costs have
reached $[insert 2023
Initial coverage limit], you
will move to the next stage
(the Coverage Gap Stage).
OR you have paid $[insert
2023 out-of-pocket
threshold] out-of-pocket
for Part D drugs, you will
move to the next stage (the
Catastrophic Coverage
Stage).]

Once [insert as applicable:
your total drug costs have
reached $[insert 2024
Initial coverage limit], you
will move to the next stage
(the Coverage Gap Stage).
OR you have paid $[insert
2024 out-of-pocket
threshold] out-of-pocket
for Part D drugs, you will
move to the next stage (the
Catastrophic Coverage
Stage).]

[Plans with pharmacies that offer standard and preferred cost sharing may replace the chart
above with the one below to provide both cost-sharing rates.]
Stage
Stage 2: Initial Coverage
Stage
[Plans with no deductible
delete the first sentence.]
Once you pay the yearly
deductible, you move to the
Initial Coverage Stage.
During this stage, the plan
pays its share of the cost of
your drugs and you pay

2023 (this year)

2024 (next year)

Your cost for a one-month
[Plans that are changing the
number of days in their onemonth supply from 2023 to
2024 insert ([xx]-day) rather
than one-month] supply at a
network pharmacy:

Your cost for a one-month
[Plans that are changing the
number of days in their onemonth supply from 2023 to
2024 insert ([xx]-day) rather
than one-month] supply at a
network pharmacy:

[Insert name of Tier 1]:

[Insert name of Tier 1]:

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Stage
your share of the cost.
[Plans that are changing the
cost sharing from a
copayment to coinsurance
or vice versa from 2023 to
2024 insert for each
applicable tier: For 2023
you paid [insert as
appropriate: a $[xx]
copayment OR [xx]%
coinsurance] for drugs on
[insert tier name]. For 2024
you will pay [insert as
appropriate: a $[xx]
copayment OR [xx]%
coinsurance] for drugs on
this tier.]

2023 (this year)
Standard cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
Preferred cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Insert name of Tier 2]:
Standard cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
Preferred cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Repeat for all tiers]

16

2024 (next year)
Standard cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Insert if insulin cost sharing
differs from cost sharing for
other drugs on the same tier:
You pay $[xx] per month
supply of each covered insulin
product on this tier.]
Preferred cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Insert if insulin cost sharing
differs from cost sharing for
other drugs on the same tier:
You pay $[xx] per month
supply of each covered insulin
product on this tier.]
[Insert name of Tier 2]:
Standard cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Insert if insulin cost sharing
differs from cost sharing for
other drugs on the same tier:
You pay $[xx] per month
supply of each covered insulin
product on this tier.]
Preferred cost sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Insert if insulin cost sharing
differs from cost sharing for
other drugs on the same tier:
You pay $[xx] per month
supply of each covered insulin
product on this tier.]
[Repeat for all tiers]

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Stage
Stage 2: Initial Coverage
Stage (continued)
The costs in this row are for
a one-month ([insert
number of days in a onemonth supply]-day) supply
when you fill your
prescription at a network
pharmacy. [Plans that are
changing the number of
days in their one-month
supply from 2023 to 2024
insert: The number of days
in a one-month supply has
changed from 2023 to 2024
as noted in the chart.] For
information about the costs
[insert as applicable: for a
long-term supply or for
mail-order prescriptions],
look in Chapter 6, Section 5
of your Evidence of
Coverage.

2023 (this year)

17

2024 (next year)

______________

______________

Once [insert as applicable:
your total drug costs have
reached $[insert 2023 initial
coverage limit], you will
move to the next stage (the
Coverage Gap Stage). OR you
have paid $[insert 2023 outof-pocket threshold] out-ofpocket for Part D drugs, you
will move to the next stage
(the Catastrophic Coverage
Stage).]

Once [insert as applicable:
your total drug costs have
reached $[insert 2024 initial
coverage limit], you will
move to the next stage (the
Coverage Gap Stage). OR you
have paid $[insert 2024 outof-pocket threshold] out-ofpocket for Part D drugs, you
will move to the next stage
(the Catastrophic Coverage
Stage).]

Most adult Part D vaccines
are covered at no cost to you
[Insert if applicable: We
changed the tier for some of
the drugs on our Drug List.
To see if your drugs will be
in a different tier, look them
up on the Drug List.]
Changes to the Coverage Gap and Catastrophic Coverage Stages
The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage
Stage – are for people with high drug costs. Most members do not reach the Coverage Gap
Stage or the Catastrophic Coverage Stage.
[Sponsors that are changing the cost sharing from coinsurance to copayment or vice versa from
2023 to 2024 insert the following sentence. If many changes are being made, the language may
be repeated as necessary. For the Coverage Gap Stage for drugs on Tiers [xx] [insert tiers], your
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cost sharing is changing from [insert whichever is appropriate: a copayment to coinsurance OR
coinsurance to a copayment].]
[Plans that do not cover excluded drugs under an enhanced benefit, OR plans that do cover
excluded drugs under an enhanced benefit but with the same cost sharing as covered Part D
drugs in this stage, insert the following: Beginning in 2024, if you reach the Catastrophic
Coverage Stage, you pay nothing for covered Part D drugs.]
[Plans that cover excluded drugs under an enhanced benefit with cost sharing in this stage,
insert the following: Beginning in 2024, if you reach the Catastrophic Coverage Stage, you
pay nothing for covered Part D drugs. You may have cost sharing for excluded drugs that
are covered under our enhanced benefit.]
For specific information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in
your Evidence of Coverage.

SECTION 3 Administrative Changes
[Insert this section if applicable: Plans with administrative changes that impact members (e.g., a
change in options for paying the monthly premium, change in contract or PBP number) may
insert this section and include an introductory sentence that explains the general nature of the
administrative changes. Plans that choose to omit this section should renumber the remaining
sections as needed.]
Description

2023 (this year)

2024 (next year)

[Insert a description of the
administrative process/item that is
changing]

[Insert 2023
administrative
description]

[Insert 2024
administrative
description]

[Insert a description of the
administrative process/item that is
changing]

[Insert 2023
administrative
description]

[Insert 2024
administrative
description]

SECTION 4 Deciding Which Plan to Choose
Section 4.1 – If you want to stay in [insert 2024 plan name]
To stay in our plan, you don’t need to do anything. If you do not sign up for a different
Medicare health plan or change to Original Medicare by December 7, you will automatically be
enrolled in our [insert 2024 plan name].
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Section 4.2 – If you want to change plans
We hope to keep you as a member next year but if you want to change plans for 2024 follow
these steps:
Step 1: Learn about and compare your choices
•

You can join a different Medicare health plan,

•

-- OR-- You can change to Original Medicare. If you change to Original Medicare, you
will need to decide whether to join a Medicare drug plan, if you don’t already have one.
If you do not enroll in a Medicare drug plan, please see Section 2.1 regarding a potential
Part D late enrollment penalty.

To learn more about Original Medicare and the different types of Medicare plans, use the
Medicare Plan Finder (www.medicare.gov/plan-compare), read the Medicare & You 2024
handbook, call your State Health Insurance Assistance Program (see Section [edit section
number as needed] 6), or call Medicare (see Section [edit section number as needed] 8.2).
[Plans may choose to insert if applicable: As a reminder, [insert cost plan name] [insert
Plan/Part D sponsor in parentheses, as applicable, after listing required cost plan names
throughout this document] offers other [insert as applicable: Medicare health plans AND/OR
Medicare prescription drug plans. These other plans may differ in coverage, monthly premiums,
and cost-sharing amounts.]]
Step 2: Change your coverage
•

To change to a different Medicare health plan, enroll in the new plan. You will
automatically be disenrolled from [insert 2024 plan name].

•

To add a Medicare prescription drug plan or change to a different drug plan, enroll
in the new drug plan. You will continue to receive your medical benefits from [insert
2024 plan name].

•

To change to Original Medicare with a prescription drug plan, you must enroll in the
new drug plan and ask to be disenrolled from [insert 2024 plan name]. Enrolling in the
new drug plan will not automatically disenroll you from [insert 2024 plan name]. To
disenroll from [insert 2024 plan name] you must either:
o Send us a written request to disenroll. Contact Member Services if you need more
information on how to do so.
o – or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-4862048.

•

To change to Original Medicare without a prescription drug plan, you must either:
o Send us a written request to disenroll [insert if organization has complied with
CMS guidelines for online disenrollment: or visit our website to disenroll online].
Contact Member Services if you need more information on how to do so.
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o – or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-4862048.

SECTION 5 Deadline for Changing Plans
If you want to change to a different type of plan, like a Medicare Advantage plan, or make a
change to your prescription drug coverage for next year, you can do it from October 15 until
December 7. The change will take effect on January 1, 2024.
If you want to change to a different cost plan, you can do so anytime the plan is accepting
members. The new plan will let you know when the change will take effect.
If you want to disenroll from our plan and have Original Medicare for next year, you can make
the change up to December 31. The change will take effect on January 1, 2024.
Are there other times of the year to make a change?
In certain situations, changes are also allowed at other times of the year. Examples include
people with Medicaid, those who get “Extra Help” paying for their drugs, and those who move
out of the service area.
If you recently moved into, currently live in, or just moved out of an institution (like a skilled
nursing facility or long-term care hospital), you can change your Medicare coverage at any time.
You can change to any other Medicare health plan (either with or without Medicare prescription
drug coverage) or switch to Original Medicare (either with or without a separate Medicare
prescription drug plan) at any time.

SECTION 6 Programs That Offer Free Counseling about Medicare
[Organizations offering plans in multiple states: Revise this section to use the generic name
(State Health Insurance Assistance Program) when necessary, and include a list of names, phone
numbers, and addresses for all SHIPs in your service area.]
The State Health Insurance Assistance Program (SHIP) is an independent government program
with trained counselors in every state. In [insert state], the SHIP is called [insert state-specific
SHIP name].
It is a state program that gets money from the Federal government to give free local health
insurance counseling to people with Medicare. [Insert state-specific SHIP name] counselors can
help you with your Medicare questions or problems. They can help you understand your
Medicare plan choices and answer questions about switching plans. You can call [insert statespecific SHIP name] at [insert SHIP phone number]. [Plans may insert the following: You can
learn more about [insert state-specific SHIP name] by visiting their website ([insert SHIP
website]).]
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21

SECTION 7 Programs That Help Pay for Prescription Drugs
You may qualify for help paying for prescription drugs. [Plans in states without SPAPs delete
the next sentence.] Below we list different kinds of help:
•

“Extra Help” from Medicare. People with limited incomes may qualify for “Extra
Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to
75% or more of your drug costs including monthly prescription drug premiums, annual
deductibles, and coinsurance. Additionally, those who qualify will not have a coverage
gap or late enrollment penalty. To see if you qualify, call:
o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24
hours a day/7 days a week;
o The Social Security Office at 1-800-772-1213 between 8 am and 7 pm, Monday
through Friday for a representative. Automated messages are available 24 hours a
day. TTY users should call, 1-800-325-0778; or
o Your State Medicaid Office (applications).

•

[Plans without an SPAP in their state(s), should delete this bullet.] [Organizations
offering plans in multiple states: Revise this bullet to use the generic name (State
Pharmaceutical Assistance Program) when necessary, and include a list of names for all
SPAPs in your service area.] Help from your state’s pharmaceutical assistance
program. [Insert state name] has a program called [insert state-specific SPAP name]
that helps people pay for prescription drugs based on their financial need, age, or medical
condition. To learn more about the program, check with your State Health Insurance
Assistance Program.

•

[Plans with an ADAP in their state(s) that do NOT provide Insurance Assistance should
delete this bullet.] [Plans with no Part D drug cost sharing should delete this section.]
Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug
Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with
HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain
criteria, including proof of State residence and HIV status, low income as defined by the
State, and uninsured/under-insured status. Medicare Part D prescription drugs that are
also covered by ADAP qualify for prescription cost-sharing assistance through the [insert
State-specific ADAP name and information]. For information on eligibility criteria,
covered drugs, or how to enroll in the program, please call [insert State-specific ADAP
contact information].

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SECTION 8 Questions?
Section 8.1 – Getting Help from [insert 2024 plan name]
Questions? We’re here to help. Please call Member Services at [insert member services phone
number]. (TTY only, call [insert TTY number].) We are available for phone calls [insert days
and hours of operation]. [Insert if applicable: Calls to these numbers are free.]
Read your 2024 Evidence of Coverage (it has details about next year's benefits
and costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for
2024. For details, look in the 2024 Evidence of Coverage for [insert 2024 plan name]. The
Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your
rights and the rules you need to follow to get covered services and prescription drugs. A copy of
the Evidence of Coverage is located on our website at [insert URL]. [Insert as applicable: You
can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if
other benefit or cost changes affect you.] You may also call Member Services to ask us to mail
you an Evidence of Coverage.
Visit our Website
You can also visit our website at [insert URL]. As a reminder, our website has the most up-todate information about our provider network (Provider Directory) [plans that do not offer Part
D, omit] and our list of covered drugs (Formulary/Drug List).

Section 8.2 – Getting Help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227)
You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.
Visit the Medicare Website
Visit the Medicare website (www.medicare.gov). It has information about cost, coverage, and
quality Star Ratings to help you compare Medicare health plans in your area. To view the
information about plans, go to www.medicare.gov/plan-compare.
Read Medicare & You 2024
Read the Medicare & You 2024 handbook. Every fall, this document is mailed to people with
Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most
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23

frequently asked questions about Medicare. If you don’t have a copy of this document, you can
get it at the Medicare website (https://www.medicare.gov/Pubs/pdf/10050-medicare-andyou.pdf) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.

OMB Approval 0938-1051 (Expires: February 29, 2024)